Inspection on 08/02/07 for Church Road (41)

This inspection was carried out on 8th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Church Road (41) 08/03/06

Church Road (41) 20/07/05

Church Road (41) 01/02/05

Church Road (41) 13/07/04

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 Church Road (41) 41 Church Road Bebington Wirral CH63 3DY Lead Inspector Beate Roth Unannounced Inspection 8th February 2007 1:00 Church Road (41) DS0000018975.V321282.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 Church Road (41) DS0000018975.V321282.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. Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Road (41) Address 41 Church Road Bebington Wirral CH63 3DY 0151 644 9493 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) Wirral Autistic Society Jane Anne Roberts Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Manager is to complete her NVQ Level 4 in Management. The Manger to be registered for 134A Allport Rd for 3 months until an application to relinquish the registration of the home has been processed. 8th March 2006 Date of last inspection Brief Description of the Service: 41 Church Road is registered to provide personal care for three adults with autism. The home is a two storey terraced property located in a residential area. On the ground floor there are 2 lounges, a kitchen with a dining area and a toilet/cloakroom. On the first floor there are three single bedrooms, an office/staff sleep in room, a bathroom and a separate toilet. There is a patio and a garden to the rear of the home. Parking is available on the main road. 41 Church Road is close to local shops and to public transport services. The home is run by Wirral Autistic Society who have several care homes for adults with a learning disability in the area. Wirral Autistic Society provides a range of services and facilities, which are fully utilised by the service users, accommodated at 41 Church Road. At the time of the inspection, the weekly cost for the service ranged from £887.00 to £1130.00. A copy of the statement of purpose, which describes the services offered at 41 Church Road, is made available to relatives and social workers. The service users guide to the home is made available before a service user comes to live at the home and the content is discussed with them to ensure their understanding. Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 5 hours and is based on a visit to the home, information received about the service since the last inspection and by questionnaires completed by the manager, service users’ relatives and healthcare professionals. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the manager. A tour of the home was undertaken. I spoke with service users and staff and observed a team meeting. A sample of financial records held on behalf of service users at the head office of Wirral Autistic Society were seen. What the service does well: What has improved since the last inspection? A monthly visit by the registered provider or their representative is being carried out on a regular basis and a written report is available at the home and a copy is being provided to CSCI. Further care planning information has been made available which provides a more detailed account of how staff are to meet the needs of service users. Communication passports have been completed for service users since the last inspection. These provide clear information on the communication needs of service users and there was evidence that staff are working with this information to support service users. Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 6 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. Church Road (41) DS0000018975.V321282.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 Church Road (41) DS0000018975.V321282.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): 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The assessment process ensures that the service is only offered to individuals whose needs can be met at the home. Service users are able to make several visits to the home to make sure it is right for them before moving in. The contracts/terms and conditions support the interests of service users. EVIDENCE: No new service users have come to live at the home since the last inspection. The initial assessment process indicates that the communication, religious and cultural needs of a new service user are considered. New service users are assessed by the manager for the home and by a representative from day services. The manager visits a prospective service user where they are living. Information is gathered from the service users’ carers, social worker and any other relevant agencies. If a service user moves to the home from another home run by Wirral Autistic Society, an assessment of the service users needs is undertaken. A discussion with the manager indicated that new service users can make a number of visits to the home to get to know the service, meet the staff and other service users. These visits are planned in accordance with the needs of Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 9 the new and existing service users. Parents/carers and representatives from placing authorities are also able to make visits to the service. A sample of contracts/statement of terms and conditions between the home and the service users were seen. These documents contain the required information and indicated that where appropriate, a representative of the service users had been involved in the drawing up of this document. In this case due consideration must be given to the provisions of the Mental Capacity Act 2005 in reaching decisions in the best interests of the service user. Church Road (41) DS0000018975.V321282.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 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. Care planning reflects the assessed and changing needs of service users. Risks are balanced with promoting independence. EVIDENCE: The service user plans were examined and contained clear information to enable staff to provide appropriate support around day-to-day living and personal goals. Since the last inspection, care-planning information has been updated to provide more detailed information for staff on meeting service users needs. A review had taken place within the last 6 months. The documentation available from reviews indicated that the service user, their relatives, social worker and other relevant individuals are invited to contribute to reviews. A service user spoken with commented positively on the support they receive from staff. A questionnaire returned by a relative indicates that they are more than satisfied with the care provided. Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 11 The service user plans indicated that service user’s rights to live as independently as possible, in accordance with their abilities, is promoted by the home. Risk assessments are available in order to safeguard service users and promote their independence. Reactive plans, which detail behaviour management strategies, are available. These assist staff in supporting service users in a sensitive way. Communication passports are available for service users. These provide clear information on the communication needs of service users and there was evidence that staff are working with this information to support service users. Service users are encouraged to contribute towards the running of the household. Service users go shopping and help with meal preparation in accordance with their abilities. Service users’ views are obtained through their individual key workers. Service users are able to make their views known about the day care services offered at a service user run advocacy group, which meets every week. The policies and procedures have been made available in formats that make them more accessible to service users where this is possible. Church Road (41) DS0000018975.V321282.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 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. Service users are able to take part in appropriate activities that provide opportunities for their educational, social and personal development. Links with the local community are promoted. The daily routines and arrangements for promoting relationships with family and friends, support service users. Varied and well-balanced meals are provided in homely surroundings. EVIDENCE: Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 13 Service users attend day services where they are provided with a range of opportunities to promote their personal development. Service users have a timetable of activities, which has been drawn up to meet their needs, skills and individual preferences. Some of the opportunities available are horticulture, craftwork, community work experience, drama and physical education. Activities are provided by either Wirral Autistic Society’s day services or by outside organisations such as local colleges. Service users are provided with work experience opportunities in accordance with their abilities. Records and a discussion with staff and a service user indicate that there are opportunities for service users to become involved in the local community in accordance with their wishes. The home has access to private transport and there is easy access to bus services. A questionnaire returned by a relative indicates that the home is very good in encouraging the residents to take part in a range of activities and encouraging particular skills and talents. Staff and records indicated that family links and friendships are promoted. The arrangements for contact with family are written into the service users’ care plans. A service user spoken with said that they have the opportunity to meet people and make friends through attendance at social clubs and through community activities. Discussions with a service user, the staff and observations confirmed that the home’s routines are flexible as much as possible and fit in with the needs and wishes of the service users. The records inspected indicate service users skills, preferred daily routines and the support service users need in their daily lives in order to make decisions and encourage independence. Care plans indicate the dietary requirements of service users. Advice is obtained from a dietician if this is required. A record is kept of food provided to service users. The records showed that well-balanced and varied meals are provided which meet the cultural background of the service users. A service user spoken with said that they help choose the meals and do the shopping and cooking with staff support. Church Road (41) DS0000018975.V321282.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 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The health and personal care needs of service users are well met. Service users are protected by the home’s procedures and policies for the management of medication. EVIDENCE: Records clearly detail the support service users need with their personal care. The routines of service users are documented and provide good guidance for staff on how to support the service users. Observations indicated that staff, promote the privacy and dignity of service users. Consistency and continuity of support for service users is provided through the key worker system. Staff receive training on promoting privacy and dignity during their induction. Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 15 Records of reviews and a discussion with a service user indicated that service users have access to medical/health care professionals as needed. Service users are supported to attend health care appointments. Service users are supported and facilitated to take control of and manage their own healthcare in accordance with their abilities. A service user spoken with said that the staff support them with their health needs. A questionnaire returned by relatives indicated that they are more than satisfied with the care provided. A questionnaire returned by a GP indicates that the home communicates clearly and works in partnership, medication is appropriately managed and staff have a clear understanding of the needs of service users. A medication procedure is available which provides clear guidance. Medication is stored securely. The records of training indicated that staff have been trained in the safe handling and administration of medication. A selection of medication administration record sheets and corresponding medication were inspected and found to be in order. Church Road (41) DS0000018975.V321282.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 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. Staff training and policies and procedures are in place to ensure that service users views are heard and appropriate action taken. The practices at the home provide protection for service users form abuse. EVIDENCE: Information is available to enable a complaint to be made by a service user or on their behalf, by an advocate. The complaint procedure includes the timescales for dealing with each stage of a complaint. The complaint procedure is displayed on the service users’ notice boards. The procedure is available in different formats to reflect the abilities of service users. A record is kept of any complaints made. The records indicated that no complaints had been made to the home since the last inspection. No complaints have been made to CSCI since the last inspection. A service user who spoke to me said that they would know who to speak to if they were unhappy at the home. Staff are aware of how to respond to a complaint. Staff reported that they continually find out the views of service users in accordance with their abilities and attempt to resolve any issues that arise. A copy of Wirral Borough Council’s adult protection procedure was available at the home. All staff that work at the home have received training in the adult protection procedures. A member of staff spoken with was able to demonstrate a good understanding of the adult protection procedures. Additionally since the Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 17 last inspection, work has taken place with service users around what abuse is, how to report abuse and steps they can take to keep themselves safe. This positive work has meant the level of understanding that service users have about how they are treated has improved and that it encourages the service users to raise issues of concern. From discussion with a member of staff and from an examination of the financial records, the home’s policies and practices with regards to service users’ money and financial affairs in general safeguard service users. Monies held at the home, on behalf of service users are checked daily by staff, audited by the manager on a monthly basis and by the representative of the registered provider at their monthly visits. Receipts are maintained and records are signed by staff. Church Road (41) DS0000018975.V321282.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 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The home provides a safe, clean and pleasant environment for service users. EVIDENCE: The premises provide a comfortable environment for service users, are in general well maintained and there is evidence of ongoing improvements to maintain standards. Attention should be given to the windowsill in the bathroom where some rotten wood is exposed. The tiles to the shower are discoloured and would benefit from being replaced. The manager has identified that these works are needed to the home and is taking action to address these. Steps have been taken to ensure the safety of service users at the home. Window restrictors and temperature-controlled water are provided. A risk assessment of the security arrangements provided by the doors at the home has taken place and steps taken to increase the homes security. Since the last inspection a number of radiator covers have been fitted in accordance with a Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 19 risk assessment. Risk assessments of radiators that are unguarded and not temperature controlled indicate that they do not pose a risk to service users. It continues to be recommended that design solutions that control the risk from radiators that can exceed 43 degrees centigrade be provided to all radiators. The home was clean and odour free at the time of the inspection. Church Road (41) DS0000018975.V321282.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including visiting the service. Service users are supported by competent staff who have access to good training opportunities. Staff are appropriately deployed to meet the needs of the current service users. However the practices around engaging individuals not employed by Wirral Autistic Society to offer therapeutic services without an appropriate level criminal records bureau check and the practice of staff taking service users to their own homes do not fully safeguard service users. EVIDENCE: An examination of the rota indicates that the home is providing sufficient staffing levels. There is one member of staff on duty at all times. There is a network of support provided by Wirral Autistic Society for lone workers. Lone worker risk assessments are available. There are currently three permanent staff working at the home with absences being covered by permanent or bank staff. Bank staff have been recruited to work for Wirral Autistic Society to cover absences in the homes if needed or to provide support within the day care service. A comprehensive induction and foundation training programme is provided to permanent staff. The induction and foundation training programmes have Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 21 been developed in accordance with the National Training Organisation training targets. This training is also provided to bank staff so as to ensure that they are appropriately trained should they need to be deployed. It is recommended that an evidence based recording system be put in place to identify that the Skills for Care workforce training targets have been met and any learning needs identified for staff. It is understood that this information is recorded for some aspects of this training. Staff are encouraged to undertake an NVQ in caring for adults with a learning disability. At present all 3 permanent staff hold a relevant NVQ. Specialist training is provided to staff to assist them to support service users as appropriate. Training is provided to staff around equal opportunities. During the inspection a team meeting was observed which, was attended by all the permanent staff and the manager. This meeting involved a thorough review of each service users needs. A professional approach was taken by the staff and there was evidence of good team working, communication and management guidance. There has been no new staff employed at the home since the last inspection. Records of recruitment were seen at the last inspection and indicated that all the required information was available. However it was apparent that a criminal records bureau check had not been undertaken for a volunteer who provides Reiki to the service users on an unpaid basis. The manager reported that this activity is supervised but there was no documentation to support this. The registered manager must remain mindful that in circumstances were someone visits the home to provide a form of therapeutic service, whether this is on a paid basis or not, then they should be subject to a criminal records bureau check in order to sufficiently safeguard the service users. The level of the check required will be dependent upon the nature of the service provided and the frequency of the involvement. At present there is no system in place for routinely updating CRB checks. The manager reported that this is in the process of being addressed. Service users visit the homes of the permanent staff that work at 41 Church Road. The manager reported that these visits are not frequent, that service users enjoy these visits, look forward to them and are a basis for positive relationships to be developed with staff. However there are a number of issues that had not been adequately considered and specifically the procedure and risk assessments for this practice were not robust enough to sufficiently safeguard service users. The effect of this practice on staff maintaining a professional relationship with service users was not sufficiently addressed. The purpose of these visits and limitations were not clearly indicated. The manager confirmed that there is appropriate insurance to cover staff taking service users to their homes and that this practice is monitored to ensure that it is not Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 22 meeting the needs of the staff rather than the service users however it was not clear as to how this is monitored. This information was not indicated in Wirral Autistic Society’s procedure for staff taking service users to their own homes. Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 23 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 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The welfare of service users is supported by a well run home and by the quality assurance systems in operation. EVIDENCE: Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 24 The manager of the home has had several years experience of management in a care setting. The manager has a Diploma in Social Work and has completed an NVQ Level 4 in management. The manager has undertaken periodic training to maintain and update her knowledge skills and competence. The manager is responsible for three other small homes that are owned by Wirral Autistic Society. A member of staff interviewed reported that they consider their views regarding the running of the home are sought and listened to. A clear complaint procedure is available. Staff meetings are held every month. There are a range of quality assurance systems in place. Wirral Autistic Society is accredited by the National Autistic Society which carries out an inspection of services provided. Wirral Autistic Society conducts an internal audit of the society as a whole on an annual basis. The views of service users are obtained by key workers and the manager. Residents meetings are held each month. Questionnaires are sent to service users and their relatives regarding how the home operates. Visits to the home by the representative of the registered provider are made. These reports are made available to CSCI. seen. The manager carries out a monthly house check of all reccords and the premises. The day service also provides a forum for service users to give their views on the services provided there. The manager reported that questionnaires for health and social care professionals are in the process of being devised. The records relating to the checks of the gas safety and electrical wiring were seen and were in order. The records of fire equipment checks indicated that the fire alarm and emergency lighting are tested at appropriate intervals and that fire drills take place on a regular basis. Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Church Road (41) DS0000018975.V321282.R01.S.doc Version 5.2 Page 26 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 YA34 Regulation 19 Requirement The registered persons must ensure that a criminal records bureau check is undertaken for any individuals who have regular contact with service users. The registered persons must ensure that the procedure and risk assessments for the practice of staff taking service users to their own homes is sufficiently robust to safeguard service users. Timescale for action 08/02/07 2. YA34 13 08/03/07 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. Refer to Standard YA24 YA24 Good Practice Recommendations It is recommended that the tiles to the shower that are discoloured would benefit from being replaced. It is recommended that attention should be given to the windowsill in the bathroom where some rotten wood is exposed. DS0000018975.V321282.R01.S.doc Version 5.2 Page 27 Church Road (41) 3. YA24 It is recommended that design solutions that control the risk from radiators that can exceed 43 degrees centigrade be provided. It is recommended that an evidence based recording system be put in place to identify that the Skills for Care workforce training targets have been completed. It is recommended that criminal records bureau checks be renewed every three years. 4. YA35 5. 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