Inspection on 18/03/09 for Faraday House

This inspection was carried out on 18th March 2009.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Faraday House 04/06/08

Faraday House 31/05/07

Faraday House 06/04/06

Faraday House 04/10/05

Faraday House 06/04/05

Faraday House 09/09/04

Faraday House 30/04/04

Faraday House 15/01/04

Faraday House 07/07/03

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2009.

CARE HOME ADULTS 18-65 Faraday House 16 Faraday Road Acton London W3 6JB Lead Inspector Sarah Middleton Unannounced Inspection 18th March 2009 10:05 Faraday House DS0000027704.V374683.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 Faraday House DS0000027704.V374683.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. Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Faraday House Address 16 Faraday Road Acton London W3 6JB 0208 248 4599 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) mrrajgopal@hotmail.com Mrs Solony Gopal Mr Runjith Gopal Mrs Solony Gopal Mr Runjith Gopal Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 3 Date of last inspection Brief Description of the Service: Faraday House is a home for people with mental health needs. The home is situated in a residential area and in close proximity to Acton town centre, a mainline railway station and major roads into London. The Owners/ Registered Managers and their immediate family reside at the home, occupying part of the ground floor and top floor of the building. People are accommodated in single bedrooms. There is a small lounge, bathroom and separate toilet on the first floor. There is a small garden to the rear of the home. The home offers twenty-four hour support and care for people, where they can access local resources such as the Community Mental Health Team. Other community amenities, such as shops and libraries are also available near to the home. Fees range from £ 520-£700 per person per week. Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. An unannounced visit was made on the 18th March 2009. Before the visit we looked at: Information we had received since the last visit made in June 2008. The Annual Quality Assurance Assessment (known as the AQAA). The AQAA gives the CSCI (now the Care Quality Commission) evidence to support what the home says it does well and gives them an opportunity to say what they feel they could do better and what their future plans are. How the home has dealt with any complaints and concerns since the last visit. Any changes to how the home is run. The Manager’s views of how well they care for the people living in the home. During the visit we: Talked with people who live in the home, staff and the Manager. Looked at information about the people living in the home and well their needs are met. Looked at other records which must be kept. Checked staff had the knowledge, skills and training to meet the needs of the people they care for. Looked around the building to make sure it was clean, safe and comfortable. We told the Manager what we found from carrying out the visit. What the service does well: The home continues to provide regular support for the people living in the home. People have the opportunity to develop skills and to gain confidence in living with others in the community. The staff team has not changed since people moved into the home and therefore people can develop positive relationships with the staff team. Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Faraday House DS0000027704.V374683.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 Faraday House DS0000027704.V374683.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New people are assessed before they move into the home to ensure the home can meet their needs. EVIDENCE: A new person had moved into the home since the last inspection visit. We spoke with this person and they confirmed they had visited the home before moving in. We viewed information sent to the home by the placing authority and the home also carried out an assessment of this person. The home’s assessment had not been fully completed or signed and dated. This was raised with the Manager and another member of staff. The home should carry out their own detailed assessment in order for them to seek information that they feel they need to know. We also spoke with the staff team regarding including questions relating to equality and diversity, such as does the person have a preference of who provides care to them. Some people might prefer personal care support or care in general by a member of staff of the same gender as they are. This should be assessed and reviewed on an ongoing basis. Faraday House DS0000027704.V374683.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. 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. People’s needs are identified and were being met. People can make daily decisions about their lives. The lack of risk assessments could place a person, or others, at risk. EVIDENCE: We viewed a person’s file to see what the home had recorded. Information about the person was seen and this is referred to as a care plan. There have been ongoing issues with the quality and detail of the care plans viewed. This has been discussed with the staff team and there were signs of some improvement. Overall the general needs of the person were recorded, although some parts of the information written about the person were too broad and would not inform a member of staff. This was raised with the staff team. The care plan had not been signed or dated by the person living in the home. Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 10 We spoke with the person, who confirmed they are involved with the completion of their care plan. Staff should ensure that the person’s involvement and views about their care plan is evidenced. Care plans need to be easy to follow and inform the staff team so that the person is supported in a safe and supported way. A front sheet with contacts such as the person’s next of kin, GP and any other relevant information was also discussed with the staff team and will be considered by the home. There was a basic handling assessment, that looked at the person’s mobility but there were no other risk assessments in the file viewed. This person goes out without staff and we were informed by the staff team that this person is vulnerable. They have lived in the home for several months and staff had not recorded the potential risks and how to minimise these risks. These shortfalls were discussed with the staff team. The support worker is in charge of developing the care plans and risk assessments. However the Manager needs to be checking that the information, once a person moves into a home, is recorded and is to their satisfaction. Information on each person must be detailed, relevant and updated as and when needs and situations change. A requirement was made for this to be addressed. The home encourages the people living in the home to make decisions about their lives. Meetings are held for all those in the home wanting to meet and ask questions or to receive information about what is occurring in the home. Where they are able to, people are supported to go out into the community without staff and encouraged to manage their own finances. People living in the home do not have independent advocates to act on their behalf. This was discussed with the Manager, who agreed to look into referring people for this type of support. Faraday House DS0000027704.V374683.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can take part in appropriate social activities both in the home and in the community. People are supported to maintain social relationships. People’s rights are respected and promoted in the home. People are offered a varied diet that meets individual preferences. EVIDENCE: The home supports people to take part in a variety of activities and tasks. One person visits different day services and drop in centres. We spoke with a person who said they were familiar with the area and could go off to visit these places as and when they wanted to. They confirmed that they like to keep their independence. Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 12 Where necessary the staff team will take people to centres and pick them up when they want to come home. People are also encouraged to help around the home and to keep as busy as they want to be. The staff team have organised in the past day trips and this will continue throughout this year. The staff team recognise that some people like to keep active and to gain skills whilst others lack motivation and need constant encouragement. Over the past inspections we have noted that the staff team have developed more of an awareness of the services in the local area and are active in supporting people to be a part of the local community and to meet other people. This is seen as good practice and should be continued. The home supports people to maintain social relationships with friends and family. Family can visit people and telephone the home. One person is in the process of getting a mobile phone and can contact family as when they wish to. One person spoken with confirmed that they receive their personal post. They raised the issue that they cannot lock their bedroom door. This was checked with the Manager and it is recommended that people should be able to lock their bedrooms, especially as one bedroom leads directly off from the communal living room. Staff must also be able to gain access from the outside of the room should there be an emergency. We viewed the menus, which were varied and healthy. One person spoken with said they enjoyed the meals in the home and confirmed they could choose what they wanted to eat. The staff team cook cultural meals to meet the individual needs of the people in the home. The staff team confirmed that everybody eats the meals together in the kitchen. As the staff team live in the home the kitchen is used by both the staff team and the people living in the home. People have full access to this room as it leads off into the garden. Faraday House DS0000027704.V374683.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. 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. People are supported in their preferred way. The health needs of people are recorded and were being met. People are not being fully protected by the home’s current medication procedures. EVIDENCE: One person needs full assistance with personal care support. The staff team had previously put into the home adaptations and equipment to assist the person to use the bath safely. Staff explained that they support people to wear appropriate clothes if this type of care is needed. Other people need very little personal care support and this is respected by the staff team. Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 14 All the people living in the home see various health professionals, such as the GP and dentist. Staff record on a medical appointments form when a person has seen a health professional so that they can monitor the person’s health needs. We viewed the home’s medication with the Manager. We checked one person’s medication. Some of the medication was in blistered sealed packs. These are colour coded for different times of the day. For example the pink sealed pack is for the morning medication. We noted that the Manager had not followed the usual system for administering the medication from these different coloured packs. For example the pink pack still had tablets in it from the previous day and the morning of the inspection. The Manager explained that he had taken the medication from a different orange coloured pack. We checked the orange pack and it would suggest that the person had received their prescribed medication from the Manager on the day before the inspection and on the morning of the inspection, as two tablets were gone from this particular sealed pack. We spoke with the Manager about not using different packs for different times of the day, as a person might be prescribed a different level/dose of medication in the morning and another in the afternoon or evening. The Manager must ensure that he follows the correct sequence in order to avoid confusion and mistakes occurring. Medication that is sent to the home, via the Pharmacist in the sealed packs, are a straightforward way of administering medication. The colours are there for the staff team to follow and the Manager needs to ensure correct procedures are being followed at all times. We noted that one prescribed medication Lactulose had not been signed for all month and the bottle was almost full in the medication cupboard. The Manager initially said the person had been receiving it but not for a few days, he then said he had not been administering it at all. The person had been prescribed this medication twice a day. The Manager must not make decisions to stop giving a prescribed medicine to a person without consulting with the prescriber, who is usually the GP. This was discussed with the Manager and a requirement was made for all prescribed medication to be administered by staff in the home. The Manager or any member of staff must not alter a person’s prescribed medication without first consulting with the prescriber, who is usually the GP or hospital staff. There was evidence that the medication had been checked once a month by the Manager and counter signed by another member of staff. However the above medication errors should have been noted during the checks. Counts and checks are in place to ensure procedures are being followed. Therefore the Manager must ensure the checks are detailed and can identify if any mistakes have occurred. Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 15 The community nurse also visits the home to administer an injection. We were informed that they bring the medication with them. However the nurse had not been signing to say what they were administering to the person. We discussed with the Manager that the nurse must sign the Medication Administration Record (MAR) each time they visit so that there is a record of the medication the person has received. The staff team need to have clear records and knowledge of all the medication a person receives, whether it is kept in the home or brought to the home by a health professional. Overall the Manager needs to monitor the medication errors noted at this inspection visit. Medication errors can have serious effects on a person and the staff team need to be confident that procedures are in place and are being followed to minimise any mistakes occurring. Faraday House DS0000027704.V374683.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 good. This judgement has been made using available evidence including a visit to this service. People can make complaints and these will be listened to and acted on. The home has guidelines and systems in place to protect people from abuse and neglect. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) completed by the Manager stated there had been no complaints in the past twelve months. One complaint we had been made aware of, was in the complaints book. We discussed with the Manager that complaints of a sensitive nature, that possibly named other people living in the home or other members of staff need to be kept in a more private area of the home and not in the kitchen where anyone can access the information. A person we spoke with said they would talk to staff if they had any concerns or complaints. There have been no safeguarding concerns since the last inspection. The home had obtained the Local Authority’s policy and procedure on adult abuse. The home has not yet updated their own policy on abuse, which needed to include information on visitors for the staff team to the home. The Manager was reminded that this needed to be carried out. Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 17 We also spoke about the home considering how to use and implement the Mental Capacity Act and Deprivation of Liberty safeguards. The Manager and another member of staff were advised to contact the Local Authority to obtain their policy and guidelines on this subject. The home has information on this subject and needs to be confident that they know what it means for people living in a care home. We counted and checked with the Manager the personal finances of two people who live in the home. The staff team support people to withdraw their own money. Where necessary the staff team work with people to budget their money so that they have enough each week for the things they want to buy. Faraday House DS0000027704.V374683.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 good. This judgement has been made using available evidence including a visit to this service. Overall people live in a clean and welcoming home. EVIDENCE: The home had made attempts to make the small living room more appealing. The room was in the process of being painted and new matching furniture had been purchased. Overall the home was welcoming and clean. Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 19 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, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from the support of a consistent and small staff team. There have been no new members of staff for sometime. People benefit from the staff team receiving ongoing training. EVIDENCE: The staff remains the same, with the Manager, his wife and son working together as a team. They remain living in the home and provide a consistent approach when supporting the people who live in the home. We were informed that the team meet together on a regular basis. There were no new staff employment files to view. The Manager is aware of the need to carry out full recruitment checks should the staff team expand. Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 20 Staff receive ongoing training on a variety of subjects. One member of staff is working towards obtaining NVQ level 4. The Manager said he would also be looking into completing the new Leadership and Management training. We were informed at the previous inspection that the Manager would be looking into an appropriate management course. This should be considered so that the Manager can develop on existing skills and acquire new skills. Overall staff had attended courses on adult abuse, fire and dementia. The home currently uses individual training records, which are useful to record each course attended. We also discussed the home having a training record of the whole staff team, so that this can be viewed at a glance. Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. People benefit from a well run home. People’s views are asked for and listened to. The lack of a detailed fire risk assessment could place people at risk. EVIDENCE: The home has been owned and managed by the same Manager for many years. As mentioned earlier, the Manager is considering studying for an up to date management qualification. Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 22 The Manager is still considering how to use the building next door which still has some outstanding maintenance work to be completed on it. The Manager has not decided if this new home will form part of the existing care home or whether it will be registered as another small care home. We will be kept informed of the progress of this. We were informed that people’s views are obtained in various ways. Meetings are held for all the people living in the home. These meetings offer people the chance to hear about what is going on in the home and to voice their opinions. The staff team also hand out questionnaires so that people can let the team know about their thoughts on the home. The staff team had yet to produce a development plan. This had been raised at the last two inspections and was discussed again with the staff team. The home should be looking to carry out continuous reviews on the home, looking at improvements that have been implemented and areas still to be addressed. Overall the staff team should record future aims and objectives so that there is a clear focus for all those working in the home. We viewed the fire book and found that fire drills had been held on a monthly basis. We also viewed a letter stating that a visit from a fire officer would be carried out in June 2008, but staff could not find an outcome letter following this visit. We were informed that a letter had not arrived regarding this visit. We had viewed at the previous inspection visit a fire risk assessment. However at this inspection visit this could not be located. It was not clear if this document had been looked at and updated or was missing. We made a requirement that this assessment is carried out using guidance and advice from the London Fire and Planning Authority. Other checks were seen, although staff had difficulty in initially locating some of the certificates, such as testing for Legionella and Gas safety record. These checks were up to date. The report and certificate for the testing of Portable Appliances could not be found at the time of the inspection. We were informed after the inspection visit that this test had been carried out on the 22.03.09. The Manager must keep all maintenance certificates and reports and make these available for inspection. Routine checks need to be carried out and the Manager must be aware of when these checks are due. Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 23 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 x 5 x 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 1 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 1 x 3 x 3 x x 2 x Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 24 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 YA9 Regulation Requirement Timescale for action 31/03/09 2. YA20 3. YA20 4. YA20 5. YA20 13(4)(b)(c) In order to protect the safety and welfare of the person and others, detailed risk assessments must be completed. 13(2) To ensure people are protected, all prescribed medication must be administered to the person and signed for. 13(2) All medication that is administered to a person, either from a member of staff or external health professional who visits the home, must be recorded onto a Medication Administration Record (MARS). 13(2) In order to avoid any mistakes occurring, people must receive their correct prescribed medication in the right sequence. The Registered Manager must ensure that medication is administered from the right colour coded sealed packs of medication for the different times of the day. 13(2) To ensure the health and safety of people is protected regular detailed medication counts and checks must be carried out. DS0000027704.V374683.R01.S.doc 18/03/09 18/03/09 18/03/09 18/03/09 Faraday House Version 5.2 Page 25 6. YA42 23(4)(a) Written evidence of these checks need to be available for inspection. To ensure the safety of the people living in the home a detailed fire risk assessment must be completed and available for inspection. 20/04/09 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 YA16 YA39 Good Practice Recommendations People should be able to lock their bedrooms so that they have privacy. Residents would benefit from the Registered Person establishing a report, which brings together information about the home, such as improvements made and views of residents. The home should consider how to implement the Mental Capacity Act 2005 and the Deprivation Of Liberty safeguards into everyday work in the home. 3. YA23 Faraday House DS0000027704.V374683.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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