Inspection on 17/07/07 for Burden Road (43)

This inspection was carried out on 17th July 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burden Road (43) 05/06/08

Burden Road (43) 28/09/06

Burden Road (43) 09/12/05

Burden Road (43) 31/05/05

Burden Road (43) 06/01/05

Burden Road (43) 16/06/04

Burden Road (43) 31/01/04

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 Burden Road (43) 43 Burden Road Moreton Wirral CH46 6BG Lead Inspector Ms Lorraine Farrar Unannounced Inspection 17th July 2007 Burden Road (43) DS0000018971.V345765.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 Burden Road (43) DS0000018971.V345765.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. Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burden Road (43) Address 43 Burden Road Moreton Wirral CH46 6BG 0151 678 9962 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) burdenroad@c-I-c.co.uk www.c-i-c.co.uk. Community Integrated Care Mark Jones Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 3 service users to include: *up to 3 service users in the category of LD (Learning Disability). 12th March 2007 Date of last inspection Brief Description of the Service: 43 Burden Road provides support and accommodation for three adults who have a learning disability. The house is a detached property in a residential area of Moreton, close to local shops, transport and facilities. Accommodation is provided over two floors. Everyone living there has there own bedroom, with two bedrooms and an adapted bathroom available on the ground floor. In addition there is a small dining kitchen and large lounge. Upstairs there is a second, smaller lounge, an office and third bedroom. Outside there is some parking and a side garden that is private. The home is operated by Community Integrated Care (CIC) LTD, an organisation who provide a range of care services across the country. Staff are available twenty four hours a day to support the people who live there. Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information for this inspection was gathered in a number of different ways. An unannounced visit took place for four and a half hours on the 17th July 2007. This included reading records and looking at the building. Time was spent looking at the support the people living at 43 Burden Road receive. This included looking at the support they get with their care plans, medication, money, activities and environment. The inspector met all of the people living at 43 Burden Road, she also met with three members of staff and had a discussion with a relative of one of the people living there. Any information the Commission for Social Care Inspection (CSCI) has received since the last inspection about the home is also taken into account in writing this report. It costs between £375.93 and £455.62 each week to live at 43 Burden Road. Social Services may contribute to this fee. An easy to understand summary of this report is available. If you would like to see a copy please ask staff working at 43 Burden Road. What the service does well: Staff working at 43 Burden Road have a good understanding of the people living there and the way that they communicate. They response positively to non verbal requests from people and ensure that routines in the house are flexible to meet peoples needs. People are supported to access healthcare appointments and to monitor their health in order to quickly identify and act upon any issues that arise. There are aids and adaptations around the house to support people with their personal care and their mobility. The people living at 43 Burden Road are able to get out and about with staff and receive one to one support from a member of staff to engage in activities that they enjoy. Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 6 Located in a residential area of Moreton the house is well located for accessing local facilities and for supporting people to become part of their local community. Regular checks are made on the safety of the building and equipment to ensure that the house is a safe place to live in. What has improved since the last inspection? What they could do better: 43 Burden Road has not had a full time manager working there for some time. Although there are plans in place for part time management support and a full time manager has been identified this may impact on the quality of the service provided. Records are not always up-to-date or accurate. In particular some records relating to medication and the support people need are out of date or have not been reviewed. This could lead to errors being made and impact on people’s wellbeing. Records relating to the people living there such as their care plan are not available in an easy to understand format. This lessens the opportunities people have to become involved in planning their care. The way in which peoples money is managed by the organisation is not clear and full records are not available within the house. This means that peoples Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 7 money may not be managed as well as it should be and may not be safeguarded. 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. Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Polices are in place to ensure people considering moving into Burden Road can be sure it is the right place for them to live. EVIDENCE: The people who live at Burden Road have lived there for some time, therefore it is not possible to practically assess the support that would be offered to anyone new who wished to move in. There is a policy in place from the organisation regarding supporting new service users. This states that a full assessment of their needs would be carried out, they would be offered information about the service and invited to visit. This process would help to ensure that sufficient information was obtained about and provided to, the person to help everyone decide if 43 Burden Road was the right place for them to live. Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living at 43 Burden Road are supported to make decisions in their everyday lives. However a lack of up to date and in-depth information about their support needs and choices may mean changes are not quickly noted and acted upon. EVIDENCE: Individual care plans are in place for the three men living at 43 Burden Road. These contained information about the things the person needs support with around their personal and health care and some information about the things they do and don’t’ like. There was some good detail recorded in care plans about how to support the person. For example one plan advised that the person felt comfortable when holding an object and staff were seen to support him with this throughout the day. All plans had communication charts which advised staff about the things they person did and what it meant, along with information about how to respond. Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 11 One plan advised that if the person sat at the kitchen table, this meant they wanted a drink. Staff were seen to respond to this throughout the visit and were also able to explain in discussion the various ways people communicated the things they did and did not want to do. Not all information in care plans was up to dare or had been reviewed regularly. One plan had not had the section on support with personal care reviewed since September 2006. This could lead to changes to the person’s needs and their choices not being quickly noted and acted upon. Information in plans was not always sufficient to ensure they gave a full picture of the person. For example under a section about ‘what is important to the person’ it was recorded that he, ‘throws objects’ ‘ gets bored easily’ ‘ wont walk on grass’. Although this information may be important to the person it does not give a rounded picture of the things that are important to them in their life. As the people who live at Burden Road don’t use verbal forms of communication it is important that as much information as possible is recorded so that those who support the person have information about how to do so successfully. Everybody’s care plan contained a series of risk assessments relating to them. These covered areas such as their environment, going out and personal care. Information was recorded regarding the identified risk and the actions that needed to be taken to minimise that risk. These had been reviewed in the past six months and were up to date. These assessments help to identity risks to the person and actions that can be taken to support the person to stay safe whilst still engaging in everyday activities. Information is not recorded in a way that is easy to understand. This means that the people whose plan it is may not be as engaged in the process as they could be. In discussions staff were able to explain the way in which the men living there make decisions and how they communicate this. They were also able to explain how they encourage people to make more decisions in their everyday lives. For example turning an upstairs room into a comfortable lounge has given a choice for one person as to whether they wish to go to bed early or sit and have time along in their lounge. Burden Road (43) DS0000018971.V345765.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, 14, 15,16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living at 43 Burden Road receive support to engage in activities that they enjoy. However inadequate facilities within the house can prevent mealtimes being a social occasion with support offered discreetly. EVIDENCE: During the site visit the men living at 43 Burden Road spent time with staff having a drink and socialising. One man was planning to go out for a meal with a member of staff later that day. Records showed that routines are flexible, with people getting up and going to bed when they choose and time spent outside of the house according to their choices. Records had some information about the leisure activities that people had engaged in. Good practice was seen in that the men receive one to one support to go out on their own with staff on a regular basis. This gives them time to engage in their chosen activities and spend time away from the people they live with. Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 13 A relative spoken with explained that they are satisfied with the support offered to their relative with leisure activities and that staff support him with the things he enjoys doing on a regular basis. In discussions with a member of staff, she explained that as well as going out for drives and meals people regularly use local shops and facilities where they are familiar with the people working there and greeted by name. This is good practice as it enables people to become part of their local community. However this along with the activities people are supported with at home is not always recorded in their records. Thorough recording of this information would enable staff to review the service they offer to ensure it matches the persons care plan and they receive the support to spend their time how they choose. Discussions with staff and a relative confirmed that the men are able to have visitors whenever they want and are supported to keep in touch with their relatives. In addition relatives had been involved in providing information to compile care plans. During the site visit staff were seen to respond positively to requests for drinks from the people living there. A set two week menu is in place, however this is a record of meals planned, not those actually served. There is therefore no clear audit trail of the food that an individual has had to eat. This information would help to ensure that people are offered a diet that meets government guidelines for staying healthy. There were limited stocks of food available in the house. Staff advised that one person was going out later for their tea and that food shopping was planned for that day and would be carried out the following morning. The only dining table in the house is in the kitchen and has seating for only three people. If everyone is at home staff have to stand around the kitchen when supporting people. This does not create a relaxed, social occasion for people to enjoy. Nor does it provide the people living there with the opportunity to learn social skills associated with meal times. Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living at Burden Road receive support to enable them to stay healthy. However recording of medication is not accurate enough to help prevent errors occurring, which could impact on the persons health. EVIDENCE: Care plans and records contain basic information about the support the person requires with their personal care and confirm that routines in the house are flexible with people getting up and going to bed as they choose. During the site visit one man was observed to have what appeared to be dried food on his face. Staff did not support him to clean this and his face remained dirty throughout the visit. One man was wearing an old, frayed jumper. Two members of staff explained that this was a favourite that he liked wearing at home and that he was supported and encouraged to get changed when going out. Although initially appearing to be unsupported with his appearance, this demonstrates that people are supported with their choices and able to relax at home. Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 15 All of the men living at 43 Burden Road have received support to attend regular healthcare appointments such as the dentist and optician. Records confirmed that where a healthcare professional requests the men are supported with aspects of their health, such as regularly checking their weight, this support is provided. Some information about the medication the person takes is recorded in their care plans. Clear information was recorded for one man about medication that he takes ‘as required’. This helps to ensure that he receives the medication he needs when necessary and that all staff have the information available to them to provide this support. However one man had a list of medications that were recorded on his care file as being current. However these were no longer on his medication sheet and a member of staff advised he no longer takes them. A lack of up to date information about medication could lead to confusion and errors occurring. Medication was stored correctly and the majority had been accurately recorded. However one man had no medication recording sheet in place. Staff advised this was due to the fact that he only has creams and as there were sufficient stocks none had been ordered, therefore no recording sheet had been delivered. Any medication that a service user is supported with must be accurately recorded so that there is a clear audit trail of when it has been given / applied. This helps to prevent errors occurring and ensure people receive their medication on time and as prescribed. Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are taken seriously and acted upon by the organisation. However organisational practices regarding the management of people’s money do not always ensure they are safeguarded. EVIDENCE: In discussion with a member of staff it was evident that they were aware of the companies procedures for dealing with complaints and allegations and their responsibilities in following these in order to ensure the people living at Burden Road are safe. Staff have received training in dealing with adult protection issues and copies of the organisations complaints policy and Local Authority adult protection policies are available on the premises to provide guidance. Information about how to complain is made available to the people living there is an easy to understand format. This is good practice as it helps to increase the opportunities for people using the service now and in the future to have a better understanding of the ways in which they can raise any concerns. A relative spoken with confirmed that she was aware of the complaints procedure and had telephone numbers she could use to raise any concerns she may have. A recent concern was taken seriously by the organisation who carried out a full investigation and took appropriate action. The organisation act as appointee for the benefit and savings money of two of the people living at 43 Burden Road. Records showed that they receive their Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 17 personal allowance from their income support each week. However there is no record of the amount of mobility money each person is entitled to weekly. This money is currently used to fund the vehicle based at the house. However although the relative of one man confirmed that she had agreed to this on his behalf, there was no evidence that representatives for the other two men had agreed this. Nor was there evidence that the organisation had considered the best options for the people concerned for whom they act as appointee. No record of the cost of the vehicle and how contributions were worked out was available. It is therefore no possible to audit whether the organisation are acting in peoples best interests and safeguarding their money. Records and amounts of money held at 43 Burden Road for people were sampled and were accurate. Burden Road (43) DS0000018971.V345765.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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 43 Burden Road provides a clean, comfortable home for people to live in. However a lack of adaptations means that some people cannot move freely around their own home. EVIDENCE: 43 Burden Road is a detached house based in a residential area of Moreton. It is similar to other houses in the local area and not distinguishable as a home that provides care services. Internally the house provides everyone with their own bedroom, which has been personalised to suit their needs and tastes. There is an adapted bathroom with walk in shower, grab rails and bath chair to help people with their mobility and personal care. Shared space consists of a small dining kitchen, which as previously identified does not allow for everyone to sit down and eat together. There is a large Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 19 lounge, which provides plenty of space for people to relax in, and a smaller upstairs lounge that one man uses to have quiet time. Outside there is some parking for the house vehicle and side gardens. A member of staff advised that there are plans to provide seating and a BBQ for the men to use. As required doors in the house are fire doors and therefore heavy to open. One man was observed to be pacing the lounge and waiting for someone to open the door for him. A member of staff confirmed that he is unable to do this for himself and therefore cannot move around communal areas of his home without help. Fire openers are not fitted to these doors so that they can be left open. A laundry room provides suitable washing and drying facilities with protective clothing and equipment in place to help prevent an outbreak or spread of infection. All areas of the house were clean and tidy during the site visit. Burden Road (43) DS0000018971.V345765.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 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living at Burden Road are supported by a staff team who understand their support needs and choices. A lack of staff training in some areas could affect the wellbeing of the people living there. EVIDENCE: Staff spoken with were able to explain the different things that the people living at Burden Road enjoy doing and the support that the need. During the site visit the men living there appeared comfortable approaching staff with non verbal requests, which were responded to positively. However as previously identified staff had not noted and acted upon one mans need for support with his personal care and appearance. Through discussion with staff and reading a sample of staff files it was evident that staff receive training in basic areas of care. These included, protection of vulnerable adults, medication and food hygiene. New staff undertake a formal induction training programme. This training helps to ensure that staff are up to date with current practice and can provide a good level of support to the people living at 43 Burden Road. Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 21 Not all staff have undertaken recent training in 1st aid. As it is identified in one mans care plan that all staff should hold this qualification, this could have a negative impact on his health. Records showed that before anyone is appointed to work at the house a series of checks are carried out. These include obtaining written references and checking with the Criminal Records Bureau (CRB) and register of people unsuited to work with vulnerable adults. These checks help to ensure the people living there are safe and that staff are suitable to support them. Burden Road (43) DS0000018971.V345765.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 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 43 Burden Road is a safe house for people to live in. Improvements to the management of the service would benefit the people living there. EVIDENCE: There has been no full time registered manager working at 43 Burden Road since the beginning of April 2007. The organisation and staff in the home advised that Annette Lea is currently managing the home. She is the registered manager of another home and staff and senior managers advised the inspector that she was working at 43 Burden Road 1-2 days per week and is always available for advice. However the rota recorded that from the end of April 07 until 8th July 07 she had worked in the house a total of three days. A lack of full time management may result in the house not being managed as effectively as it should be and Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 23 the service not being of a high quality. If a manager is working in the house and their hours not recorded on the rota there is no clear audit trail of who was providing support to the people living there at any particular time and no clear record of the management support provided. There are several systems in place for reviewing the quality of the support provided at 43 Burden Road. The organisation carry out a yearly audit of their services including sending out questionnaires. The results of these are published and senior managers have advised that there are plans to individualise the results of these for each service. Each month a senior manager from the organisation visits the house and carries out a review of the service. This covers staffing, resources, care and planning. A review carried out in June 07 states that, “all relevant paperwork reviewed and up to date”. As parts of care plans had not been reviewed for some time this statement is not accurate. Records and certificates showed that regular heath and safety checks and tests are carried out to ensure the house is a safe place for people to live in. Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 X 2 X X 3 2 Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 25 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 YA7 Regulation 15(2)(b) Requirement Care plans must be regularly reviewed and up to date. This will ensure that full and accurate information is available about the people supported at all times. 2. YA17 17(2) An accurate record of meals served must be kept. This will ensure that there is a clear audit trail to ensure people are offered a healthy diet that meets their needs and choices. 3. YA20 13(2) Information regarding medication for people must be accurate and up to date. This will help to prevent errors occurring. 4. YA23 13(6) A full assessment of the way in which people’s money is managed by the organisation must be carried out. This must include information on the amount of money they receive. DS0000018971.V345765.R01.S.doc Timescale for action 20/09/07 30/08/08 30/08/07 30/09/07 Burden Road (43) Version 5.2 Page 26 A rational as to why they contribute towards a shared vehicle. The costs of this vehicle and how the contribution is worked out. This will help to ensure people’s money is safeguarded. 5. YA24 23(20(a) A risk assessment must be 17/09/07 carried out on accessibility within the home and action taken on any findings. This will ensure that people can move around shared areas of their home freely. 6. YA35 18(1)(a) A written assessment of training staff should undertake must be carried out. This must take into account the individual needs of the people living there. This will help to ensure people are safe and supported correctly. 7. YA37 17(2) A full and accurate record of the hours worked by the manager of the home must be available. This will help to ensure the home is correctly and adequately managed. 30/08/07 17/09/07 Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA7 Good Practice Recommendations Care plans should be provided in an easy to understand format, This will support people to understand the contents of their plan more easily. 2. YA14 Information regarding the support people are provided with around how they spend their time should be recorded in more detail. This will help to check that people are receiving the support that they want to spend their time how they choose. Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Burden Road (43) DS0000018971.V345765.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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