Inspection on 23/08/06 for 145 -146 Goddard Avenue

This inspection was carried out on 23rd August 2006.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Goddard Avenue (145) 145 Goddard Avenue Old Town Swindon Wiltshire SN1 4HX Lead Inspector Pauline Lintern Key Unannounced Inspection 23rd August 2006 10:00 Goddard Avenue (145) DS0000067326.V304852.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 Goddard Avenue (145) DS0000067326.V304852.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. Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Goddard Avenue (145) Address 145 Goddard Avenue Old Town Swindon Wiltshire SN1 4HX 01793 279870 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) XLCARE LIMITED Ms Zehrida Arif Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The staffing arrangement referred to in the letter dated 4th April 2006 must be complied with for a minimum of 6 months from the date of registration. The 2 existing service users aged over 65 years (referred to in the application form dated 20th March 2006) may be accommodated at the home whilst the home can demonstrate that their needs can be met. 22/03/06 Date of last inspection Brief Description of the Service: 145 Goddard Avenue is a care home providing accommodation for seven people who have a learning disability. XLCare owns the home and the proprietor also has the day-day management responsibilities. The home is located in a residential area in Old Town, Swindon. It is situated within easy access to local shops and amenities and is also on the main bus route into Swindon town centre. It is a three storey terraced house, with five single bedrooms, and one shared bedroom. The garden is large and well maintained, with ready access for all residents. Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over seven and a half hours. The registered provider/manager, Ms Zehrida Arif was present to assist the inspector. Ms Arif has been the proprietor since May 2006. The inspector met with four residents during the course of the day. Surveys were sent out to residents and their relatives prior to the visit to the service. Two staff was available to share their views with the inspector. During the inspection various documents were sampled. These included health and safety records, risk assessments, care plans, staff recruitment files and training records. The inspector was invited to view the shared bedroom and two residents showed the inspector the rest of the communal areas in the house. What the service does well: What has improved since the last inspection? The recording and storage of medication has now improved. The manager is developing methods of ensuring service users’ goals are achievable and that staff support is available. All documentation is being updated to ensure that it is relevant to the service user’s needs. The manager has many ideas on developing the service further. New tools for aiding communication are being developed. Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 6 Staff are encouraged to participate in the development of person centred planning. The manager has looked at ways of ensuring that staff members have a sound understanding of the National Minimum Standards. 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. Goddard Avenue (145) DS0000067326.V304852.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 Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Prospective residents are fully assessed prior to being offered a service to ensure that their needs can be met. Residents have a copy of the service user guide although much of the information contained in them is out of date. Quality in this outcome area is adequate. This judgement has been made by evidence gathered both during and before the visit to the service. EVIDENCE: There have been no new admissions to the home for a long time. We discussed the assessment process and Ms Arif has plans to ensure that there is a complete, concise breakdown of the service to be provided, this will include fees, staffing required, specific training and any health care or behavioural input that may be necessary to met the resident’s needs. Ms Arif showed the inspector a draft copy of this document. She added that any potential new resident would have the opportunity to visit the home, have a meal and stay overnight if they wish. It is reported that all of the existing residents will have the opportunity to meet the new person and confirm that they are happy for them to move into their home. The manager stressed that she feels it is very important that the residents are consulted on any changes, which may take place. Two residents showed the inspector their service user guides, which they had in their bedroom. Much of the information in them was either missing or out of date. The manager confirmed that she is aware that the service user guides need to be reviewed and updated. She reported that she intends to develop all Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 9 documentation into an easier format for the residents using pictures, symbols or any other appropriate method. We discussed the ‘Change’ picture bank method of easier access to the summary section of the inspection report, which the commission has adopted. Ms Arif has agreed to feedback to the inspector on how it is received by the residents at 145 Goddard Avenue. Ms Arif has plans to redesign the homes’ brochure to make it more accessible and welcoming. Goddard Avenue (145) DS0000067326.V304852.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 Each resident has a care plan, although one care plan that was sampled indicated that it had not been reviewed recently. Residents are empowered to make decisions about their life and are supported to do so if appropriate. Risk assessments are in place, however there is no evidence to show that they have been reviewed recently. Quality in this outcome area is adequate. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: Three care plans were examined during the inspection. One indicated that it was due for review in May. The manager explained that she has made several attempts to arrange a meeting with Oxford County Council who are short staffed and apparently no longer attend reviews. She added that due to particular residents changes in health needs they review their care plan on a regular basis, the last one being September 15th 2006. Care plans contain comprehensive information on the residents’ medical needs, mobility, communication, personal care and likes and dislikes. Discussion with the Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 11 manager demonstrates that she is keen to develop the existing person centred plans, which are in their early stages and has plans to re-visit all residents’ care plans to make them more user friendly. The manager intends to encourage residents to contribute to all aspects of developing their care plan by exploring different communication tools. Two residents report that they attend and participate in their review meeting. The manager commented that all residents are encouraged to attend their meetings if they choose to. The ethos of the home is to promote independence and to encourage residents to make decisions and choices about how they wish to live their lives. During the inspection residents were observed making decisions with regard to activities within the house. One resident told the inspector that they had chosen to stay home that day as they wished to carry out some household tasks. Risk assessments are in place but some do not evidence that they have been reviewed. The manager confirmed that all risk assessments would be reviewed shortly as part of developing the care plans. Goddard Avenue (145) DS0000067326.V304852.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, 15, 16 and 17 Residents are able to access appropriate activities if they wish to do so. Residents are part of the local community. Family contact is encouraged. Residents make choices and participate in the running of the home. Menus show that meals are well balanced and nutritious. Mealtimes are flexible to suit the residents’ needs. Quality in this outcome area is excellent. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: During the inspection one resident had returned from Upham day centre. Although the resident was unable to vocalise they indicated that they had enjoyed themselves by smiling and looking happy when asked if they had had a good day. Another resident was waiting for taxi to take them to Therapeutic Work in Gardening in Swindon (TWIGS), which they said they really enjoyed. On their return to the home they said they had been picking tomatoes and had brought some home for everyone to enjoy. Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 13 The manager explained that she was hoping to widen social links for a couple of the residents who tend to stay at home more. The residents confirmed that they would like to explore golf and other new activities. Residents discussed their holiday plans for September with the inspector. The manager reported that she had bought in brochures and a video of centre parcs to see if the residents would like to go there. They then discussed the activities available there to ensure that everyone was happy with the choice. It was obvious that a great deal of thought had gone into the planning of the holiday to make sure that everyone’s needs and abilities could be met. Residents had recently attended an Asian festival, which they appeared to enjoy although one resident commented that ‘the food was a bit hot’. The manager said that some evenings they hold a cultural evening when they may have Mexican or Indian food for a change. Some residents go to the Old Town Gardens to listen to the brass bands. Residents appear to be well known in the local community. It is reported that local shops make the residents welcome when they visit. Residents living at the home are encouraged to have relationships and their diversity is respected. Family contact is promoted and the manager explained that she has started meeting with all relatives to enable them to build good relationships together and to have an opportunity to share views. She reported that one relative has recently moved away, which has been fairly upsetting for both parties. However they have discussed how they can ensure that the resident does not feel lonely. They have agreed to make more telephone calls and send postcards and they have agreed to meet halfway to help ensure that regular trips home can still take place. The home is planning a barbeque and intends to invite families and friends to attend. It is reported that all residents are offered a front door key however some choose not to have one. During the inspection one resident was observed collecting the post and opening their own mail. Residents at Goddard Avenue all take part in the day-to-day running of the home. People were observed carrying out household tasks such as washing and preparing shopping lists. Residents are encouraged to make decisions within the home. Two residents told the inspector that they are retired and therefore choose not to go to a day centre, preferring to stay at home. The manager explained that she has just introduced a ‘residents request’ book. This will ensure that requests do not become forgotten. Mealtimes are flexible to fit in with the day’s activities. Residents showed the inspector the menus and explained that each day one person helps prepare and cook the evening meal. One resident’s care plan outlines their specific dietary needs and the menu supports this. On the day of the inspection staff were observed offering the residents’ choices for lunch. The meals appear varied and nutritionally well balanced. The atmosphere of the home is one of good interaction between the residents and the staff. Goddard Avenue (145) DS0000067326.V304852.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 Personal support is provided in a way that is preferred. Staff support residents with their physical and emotional needs. Service users are protected by the homes policies and procedures for medication handling and supported to manage their own medicine where appropriate. Quality in this outcome area is good. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: The home encourages residents to be as self-managing as possible. Residents report that they choose when they get up and go to bed. One resident said that she had stayed up late the night before the inspection. Care plans sampled detailed the amount of support and assistance people may require. The inspector noted that staff had kept a record of a particular hair colour, which one resident used to ensure that it was the correct one. The manager was observed offering reassurance to one resident with regard to a planned trip to the dentist. Specialist services are accessed such as the diabetic clinic, where guidance is sought. Residents have access to healthcare facilities such as psychiatric nurses, doctors, opticians and dentists. The manager demonstrates a good understanding of one resident’s emotional needs. She is ensuring that the resident’s long term goals are achievable and Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 15 well planned to enable them to move on to more independent living, while still reflecting on all aspects of risk that need to be considered. Residents have a health action plan however there is no date showing when they were last reviewed. Service users who are able and willing are supported to manage their own medicines. The processes are reviewed regularly and designed individually depending on need. The risk assessment for one service user was not available at the inspection, but was sent to the inspector the following day. All other medication is stored and administered appropriately following a procedure which all staff sign. Records were kept of all medicines received into the home, administered or returned for disposal. The manager produces written medication administration sheets for each service user and discussed changes she may make to this process, including changes to the recording of ‘homely remedies’. Under the current system any written entries should be signed, dated and checked by two members of staff. The sheets must be kept up to date and any medicines no longer in use removed. A new policy and procedure had been recently introduced which covered all aspects of medication handling in the home, however it should contain guidance about what needs to be done if a medication error should occur. Staff have received ‘Safe handling of medication’ training from an outside source and information about medicines is available in the home for staff to use. Goddard Avenue (145) DS0000067326.V304852.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 Residents have the opportunity to share their views and know that they will be acted on. Residents are safeguarded from abuse where possible. Quality in this outcome area is good. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: Staff confirmed that they have access to the ‘No Secrets’ guidance, which the home is signed up to. The home has a whistle blowing policy. Staff that met with the inspector confirmed that they would have no hesitation to report any suspected abuse. The home has a complaints policy and procedure, which the manager hopes to develop into a more ‘user friendly’ format for the residents. There have been no complaints made since the last inspection. The home has a complaints log. Staff support residents in 1-1 supervisions, when they have the opportunity to raise any concerns if they wish. The manager commented that house meetings are also planned for residents. Staff report that they have attended abuse awareness training. Two staff told the inspector the procedure they would follow if they had any suspicion that any form of abuse had occurred. The home’s policies and procedures for handling residents’ money were discussed with the manager. One resident’s financial records were sampled and receipts balanced correctly. Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 17 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 30 145 Goddard Avenue provides a safe and homely environment for the residents. At the time of the inspection the home was clean and hygienic. Quality in this outcome area is good. This judgement was made from evidence gathered both during and before the visit to the service. EVIDENCE: Two residents took the inspector around the house and showed her their bedroom. The bedroom had been made comfortable and there was a television and comfortable chairs. There are pictures and photos all around the house, which gives it a homely feel. The lounge has lots of games, books, videos and a secluded dartboard. The lounge opens up onto a decked sitting area for residents to sit on when the weather permits. Staff report that they have attended Infection Control training and the home has a copy of the infection control guidance. Residents were observed doing their laundry. The home has recently purchased a new washing machine, which meets the home’s requirements. All residents share the responsibility of household tasks. Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 A competent and qualified staff team supports residents. The home’s recruitment policies and practices safeguard residents where possible. Staff are appropriately trained to meet the needs of the residents. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. EVIDENCE: The manager reported that since the new ownership all staff have received individual supervision and there has been one staff meeting. She hopes to encourage the staff to engage in the discussions and to use this forum to share ideas. Three staff files were examined and they showed that they have attended training in various subjects such as podiatry, basic food hygiene, personal hygiene, handling of safe medicines. The manager confirmed that one staff member is in the process of completing their National Vocational Award (NVQ) level 4, one has level three and one has level two. Two of the three staff recruitment files examined belonged to long serving staff and the manager reported that their application forms and references would be archived by now. The most recently appointed staff member’s file had a copy of their application form, CRB check and two references. The inspector recommended that staff recruitment files are now kept available for examination if necessary. Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 19 All three files demonstrated that checks had been made with the Criminal Records Bureau (CRB) prior to commencement of employment. There appeared to be some confusion as to requesting a check against the POVA list also. The authorised body for submitting CRB’s had informed the manager that there was no need to complete this check. However after some discussion it was felt that they had confused this with the POVA first check, which is used in emergency situations when there is a need to seek clearance quickly. The manager is going to clarify the situation. Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The home is well run by a competent manager. Residents are encouraged to share their views on the service provided. Where possible the health and safety of residents is safeguarded. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. EVIDENCE: The manager is currently working towards her National Vocational Qualification (NVQ) level 4. Discussion with her during the inspection indicates that she has strong management skills and will be looking at ways of promoting independence and empowering individuals to make decisions about their lives. She has identified areas that she wishes to build on for residents such as communication skills and person centred planning. The manager explained that she intends to work through the National Minimum Standards with the staff team to ensure compliance and a clear understanding of their implications. The manager reports that she accesses information and guidance Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 21 form the commission’s web page. Each resident has a written contract which outlines the terms and conditions. The manager is in the process of developing a questionnaire, which will be sent out to residents, families and agencies to obtain their views on the service provision. Recently Swindon Borough Council sent out questionnaires for their service planning and research database to each resident, Staff explained this with each resident during their one to one supervision to ensure that they understood the contents. All accidents are recorded and are stored in line with the Data Protection Act. All toxic materials are securely locked away and data relating to the materials is available. The fire logbook showed that the alarm system was last tested on 18/08/06. The emergency lighting and fire fighting equipment was tested on 03/08/06. Records showed that a fault had been identified and rectified immediately. The last fire drill took place on 21/07/06. Bristol Fire carried out their last check at the home on 04/08/06. The manager confirmed that all staff attend infection control training and follow up refresher courses as necessary. New staff confirmed that they had received a full induction period and the process is on-going. Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 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 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation Requirement Timescale for action 23/11/06 2 3 YA6 YA1 13(4)(abc) The registered person shall ensure that all risk assessments are reviewed regularly and recorded. 15(2)(b) The registered person must keep 23/11/06 the service user’s care plans under review. 5(1) The registered person must keep 23/11/06 6(a)(b) the service user’s guide under review. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA20 YA20 YA19 Good Practice Recommendations The medication procedure should contain information and guidance about what staff need to do in the event of a medication error. Written medication administration records should be signed, dated and checked by two members of staff. It is recommended that all resident’s health action plans are dated when they are completed. Goddard Avenue (145) DS0000067326.V304852.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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. 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