Inspection on 30/08/06 for Fernica

This inspection was carried out on 30th August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fernica 24/09/07

Fernica 23/03/06

Fernica 20/04/05

Fernica 04/10/04

Fernica 06/04/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

Thames House

Creative Support

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

CARE HOME ADULTS 18-65 Fernica Fernica 18-20 Kings Road Prestwich Manchester M25 0LE Lead Inspector Unannounced Inspection 30 August 2006 10.00a th Fernica DS0000044739.V297658.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 Fernica DS0000044739.V297658.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. Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fernica Address Fernica 18-20 Kings Road Prestwich Manchester M25 0LE 0161 773 6603 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) Miss Marguerite Clark, Mrs Miriam Elizabeth Laventiz Miss Marguerite Clark Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced Manager who is registered with the NCSC. The matters detailed in the attached schedule of requirements must be completed in the timescales. 23rd March 2006 Date of last inspection Brief Description of the Service: Fernica is a small care home providing accommodation and support for up to 14 people with mental health needs. The fees range from £359.00 to £550.00 this is dependent on the assessed needs of individuals. The home is located within the Prestwich area and is close to all local facilities. Public transport may be easily accessed for Bury, Prestwich Village and Manchester City Centre. The home is made up of two semi-detached houses, which have been converted into one property. Accommodation is provided on three levels. There is no lift facility. The home is a family run home, offering accommodation to adults with mental health needs and is staffed on a 24-hour basis. The home caters for both short and long stay service users. All bedrooms are single however no en-suite facilities are provided. Of the bedrooms, two do not meet the spatial requirements as stated within the National Minimum Standards. This information has been detailed within the homes Statement of Purpose. Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. The inspector spent time looking round the home, viewing records as well as talking with residents and staff. Discussion and feedback was also held with the Manager. The home is registered to provide accommodation for 14 people. At the time of the visit the home had 2 vacancies. Although the inspection was unannounced the completion of a pre-inspection questionnaire was requested. Feedback surveys were also distributed to residents, relatives and health and social care professionals. Completed surveys were received from 10 residents, 5 relatives/visitors, a GP, CPN and Social Worker. Comments have been added to the report. All the key standards were looked at during this inspection visits. What the service does well: What has improved since the last inspection? The Manager has carried out all the work, which was identified at the last inspection making sure that the home is safe and comfortable for residents. This has included work being carried out to the environment, new furniture items being bought, checks in relation to health and safety, staff recruitment and training. Fernica DS0000044739.V297658.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. Fernica DS0000044739.V297658.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 Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed information as well as opportunities to spend time at the home allow both prospective residents and staff to make an informed decision about the suitability of the placement and whether their needs can be fully met. EVIDENCE: Since the last inspection there has been one new residents and a second person that is currently visiting the home as part of the assessment and resettlement process. Information was examined for both individuals. Information regarding the new resident had been provided by the mental health social worker involved, this included background information about areas or concern/need, family support, risk areas and hospital admissions. Information about the second person, who has yet to have a placement formally agreed, was very detailed. Support is currently being provided under a formal section at a local hospital and will require a tribunal to agree discharge. Very detailed information had been supplied by both health and social care professionals involved detailing extensive information about the individuals past and present mental health, behaviours, risk, support etc. Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 9 The Manager was very clear that the need for detailed information was important in order for a safe placement to be agreed, considering both the current residents and the individual being referred to the home. As already stated individuals are able to spend time visiting the home, staying for meals or overnight enabling them to spend time with other residents as well as allowing staff to gather more information about their routines, needs etc. This is undertaken over a period of time, which is felt necessary for the individual and home so that an adequate assessment can be made to inform their decision about the suitability of the home. Placements are then reviewed as part of the hospital discharge and/or placement agreement following the initial 6 to 12 week period. Evidence of these meetings is held on file. Comments received from residents confirmed that they had been involved in making a decision about moving into the home. These included; ‘I came to look round and fell in love with it’, and another had been brought to the home by their social worker to see what they thought about moving in. Fernica DS0000044739.V297658.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 at least once during a 12 month period. 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 a visit to this service. Residents care plans and assessments clearly identify their support needs and how these are to be met ensuring their health and well-being is maintained. Residents expressed they were well cared for and were clearly involved in making decisions about their lives. EVIDENCE: Documentation and records continue to be held in relation to each of the residents. Each of them has a care file, which includes all information following the initial assessment to care planning, risk assessment, health reviews, correspondence and financial information. Additional records are made with regards to daily reports, professional visits and appointments, personal care (where necessary), weight and personal monies. Files are orderly, up-to-date and clear. Plans continue to cover all areas in relation to the persons’ physical, social and emotional well-being including their routines, religion/culture and finances. Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 11 This identifies areas of need, goals, support requirements and risk assessments. Plans are reviewed on a regular basis or as needs change. This was evidenced on those files seen. The residents had also signed plans. Further reviews are also held with mental health professional as part of the formal discharge programme (CPA) and information is held on file. These are held either 3, 6 or 12 monthly basis dependant on the identified needs. The Community Psychiatric Nurses (CPN) provides additional support and advice. Should any concerns be noted the mental health professionals involved would be notified. Where particular areas of risk have been identified assessments have also been completed. These were seen to cover issues such as, alcohol use, suicide, behaviours etc. These too are monitored and reviewed where necessary ensuring the safety and well being of residents and staff. It was discussed with the manager the areas of concern in relation to the new referral. Should the placement be agreed the Manager must ensure that clear and detailed assessments are in place to cover all areas of risk along with the necessary management strategies and external support systems, ensuring that the complex needs of the individual as well as the well being of residents are maintained. A number of the residents were spoken with as a group and individually. It was noted that some of the residents were more alert and willing to engage in conversation. Residents appeared happy and settled and enjoyed a good rapport with each other. Some of the feedback received from the resident surveys included, ‘I’m very happy and content at Fernica’, ‘it’s a nice home to live in’, ‘I can go out when I want’, ‘staff treat me well and listen to me’, ‘the house is nicer now it has been decorated’, ‘Fernica has made me more independent in what I want to do’ and ‘the housekeeper does a good’. Fernica DS0000044739.V297658.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents pursue a variety of activities both in and away from the home enabling them to develop skills and increase their independence. Residents continue to maintain contact with family and friends. This is encouraged so that residents benefit from other relationships and friendships. EVIDENCE: Each of the residents are able to make decisions about their lives and daily routines enabling them to increase their independence or learn new skills. Residents come and go freely pursuing activities of their choosing with or without support. This was observed during the inspection. Some of the residents still attend the therapeutic employment scheme and attend a local drop-in whilst other prefer to chose activities around the home. A variety of leisure activities are followed and include occasional meals out, day trips, library, music lessons as well as tasks within the home or relaxing Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 13 watching the television or videos and listening to music. This is based on individual preferences and wishes and enhance lives and skills. Arrangements were being made for further trips including the cinema and Blackpool lights as well as the Christmas meal. One residents was looking forward to his birthday and having a party at the home. Residents expressed that they had enjoyed the recent trip to Southport. At present all but three of the residents have a travel pass allowing them easy access to public transport between Bury and Manchester. The home is also situated close to all amenities including shops, take-away, post office, church and synagogue. Seven of the residents also have additional staff support provided from their CPN’s, social worker or Creative Support workers who provide 1-2-1 sessions supporting residents in accessing community facilities as well as developing more practical skills. Residents also maintain contact with family and friends. One resident had previously been on holiday with family members and arrangements are made for individuals to have overnight visits away from the home. Visits also take place at the home from family, friends and members of the local Jewish community, particularly around festival times. Fernica DS0000044739.V297658.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ mental health needs are consistently met. Additional support is required in relation to encouraging service users to maintain their personal care. Relationships with mental health professionals are effective and provide positive support networks. Medication storage and administration is safely managed. EVIDENCE: In relation to personal needs, most of the residents are independent and able to manage for themselves. Staff said that at times they needed to prompt and encourage some of the residents. Where support is provided this has been detailed within the care plan. Residents said that they had choices about their daily routines, for example what time they got up. This was seen on the day of the inspection with some of the residents still in their bedrooms, whilst other were either in the lounge or had already gone out. Residents said that they were very happy with the way they were supported by the team and how they were spoken with. Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 15 Clear information is recorded with regards to all contact with health professionals. Records showed that the home requested assistance from specialist health workers if necessary. These may include, community psychiatric nurses (CPN), social workers, consultants, dietician, GP As previously identified the mental health needs of residents continue to be closely monitored by both staff at the home and those that offer support from the mental health team ensuring the well-being of residents is maintained. Where concerns are identified the appropriate action can then be taken. Formal reviews continue to be held and minutes recorded detailing the stability/changes of each resident’s mental health. A number of the residents continue to receive support from social workers and care providers who provide 1-2-1 input enabling them to accessing places within the community enabling them to develop new skills and build confidence. The medication system was examined. This was found to be safe and records had been completed in full. Records are made of all items delivered and returned to the supplying pharmacist. A recent audit had been carried out be the supplying pharmacist. This was found to be satisfactory and a copy of the report seen by the inspector. Residents’ medication is also regularly reviewed with health professionals ensuring the stability of their mental health. At present none of the residents in receipt of medication self-administer. Feedback was also received from health and social care professionals who also provide support to the home. Comments included, ‘always been very please with the support, care and communication with service users, carers and professionals’. Fernica DS0000044739.V297658.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place with regards to the complaints and adult protection issues. Relevant training is still needed for some members of the team ensuring that residents are safe and protected. EVIDENCE: A copy of the home’s complaints procedure is displayed within the home as well as being included with the Service User Guide. Copies of this document are available in each of the bedrooms therefore easily accessible to each of the residents should they wish to raise any issues. No issues have been raised with either CSCI or the home. Comments made by residents within the surveys confirmed that they were aware of what to do if they had any concerns. One resident expressed ‘If I have any questions I just ask’. Residents spoken with confirmed that they had no concerns and where happy to approach the staff if they needed to discuss anything. In relation to protection, relevant policies and procedures home. The majority of staff have received training in however this is still required for an existing member of the recruit. The Manager is to make arrangements for this to be are held by the adult protection team and a new completed. With regards to residents finances support is offered. Fernica acts as the appointee for 3 residents with other support being provided by the local authority or named solicitor. Where able individuals manage their own affairs. Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 17 Personal allowance are held by the home and agreements made with regards to how this is to be managed. A number of residents are on a budget plan, which supports them in managing their money throughout the week. Clear records are made of all transactions along with receipts. Residents also sign to evidence receipt of any money. Fernica DS0000044739.V297658.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 at least once during a 12 month period. 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 a visit to this service. On-going redecoration and refurbishment has taken place, which has only further enhanced the appearance of the home providing comfortable accommodation for those living there. EVIDENCE: Fernica is a large detached property, originally two houses, which have been made into one. Accommodation is provided on 3 floors and comprises of 2 lounges, one of which is the designated smoking area, dining room, sitting area and kitchen. There are 14 single bedrooms and 4 full bathrooms, one of which provides assisted bathing enabling further support to be provided for residents in managing their personal care needs. A separate laundry room is also available on the 1st floor. Over the last year the owners of the home have carried out redecoration and refurbishment in a number of areas around the home. This has enhanced the appearance of the property, providing a brighter, more homely environment Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 19 for those who live there. Previous action identified had been addressed. One resident expressed that he was pleased with the work carried out stating ‘it has made a big improvement to the home’ and ‘they have worked hard to get it nice’. Some of the recent work undertaken has included, new PVC windows being fitted, new bedroom furniture, damp in one bedrooms has been addressed, new flooring and redecoration of the dining room and several bedrooms redecorated and new TV aerial in several rooms. The home also employs a housekeeper and handyman who undertake the majority of tasks within the home. Rooms where found to be clean, tidy and well maintained. One resident commented that ‘the housekeeper does a good’. A separate office, with sleep-in facilities is also available for staff on the lower floor. Fernica DS0000044739.V297658.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff at the home are in sufficient numbers to meet the needs of residents. On going training and support is to be provided to equip staff with the knowledge and skills needed in meeting the needs of service users. EVIDENCE: The staff team at Fernica is small and comprises of 2 owners, 1 full-time carer, 2 bank and a housekeeper. all staff are aware of their role and responsibilities. Staff communicate with each other on a day-to-day basis, therefore have a good understanding in relation to the needs of the residents and events, which have occurred each day. Since the last inspection visit no new staff have commenced working at the home however the manager is in the process of recruiting a bank worker who has previously worked at the home. The Manager must ensure that the relevant checks including new references and a criminal record check are undertaken prior to employment. Training has been provided. Two of the existing team are qualified nurses, another member of the team has completed NVQ in levels 2 and 3, covering mental health care and a further carer is currently completing the course. Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 21 The Manager/owner has also recently completed the NVQ level 4/Registered Manager Award. Her portfolio of evidence has been submitted for verification. Further courses have been provided to some members of the team covering adult protection, infection control and first aid. These are to be arranged for those staff that have yet to attend. In relation to staff supervisions, the manager is aware of her responsibility in this area however this has not yet been introduced. Arrangements are to be made for the two providers to share the role and information is to be recorded and placed on file. Fernica DS0000044739.V297658.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home continues to be effectively managed ensuring residents are consulted with and involved in the development and plans made for the home. Responsibilities in relation to health and safety are also addressed. EVIDENCE: Fernica is a family owned home. Changes have recently taken place with regards to the Registered Providers. This has been dealt with by the CSCI. As previously identified the Registered Manager is also one of the owners. She is a qualified nurse and had worked at the home for many years prior to becoming the owner/provider. The Manager has recently completed her NVQ level 4/Registered Managers Award. This has now been submitted for verification. Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 23 In relation is quality monitoring, the home regularly liaises with the residents during formal residents meetings and informally through day to day discussion. Further feedback is also sought from residents and families through the formal review meetings, which are held with social workers and mental health professionals. Staff feedback is also sought from the staff during the periodic team meetings. The Manager also stated that periodically questionnaires are distributed. Whilst these have been provided to residents they have yet to be sent out to other parties involved with the home. A formal staff supervision system still needs to be implemented so that further feedback and information can be gathered from staff. Consideration needs to be given to developing an internal monitoring system developing a report and any action that may be required in relation to the findings. With regards to health and safety, the handyman carries out regular checks within the home, this includes fire safety, water and small appliances. Further checks are carried out ensuring the safety of staff and residents and certificates are held within the home. A minor shortfalls was in relation to the Coshh assessments, these need to be reviewed an updated where necessary. The accident/incident book was seen, information had been recorded appropriately. The Manager is also aware of her responsibility with regards to Regulation 37 in relation to the CSCI being informed of all incidents, which may affect the well being of residents. Fernica DS0000044739.V297658.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 3 3 X 4 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 18 Requirement Arrangement should be made for the remaining/new staff to complete training in adult protection. Arrangements should be made for the relevant refresher training required for staff. A supervision system should be implemented offering staff the relevant support and guidance. The Coshh risk assessments need to be reviewed and up dated. Timescale for action 30/11/06 2. 3. 4. YA35 YA36 YA42 18 18 13 30/11/06 30/11/06 30/11/06 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 YA39 Good Practice Recommendations That consideration is given to the development of a quality assurance system and a report in relation to the findings. Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fernica DS0000044739.V297658.R01.S.doc Version 5.2 Page 27 - 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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