Inspection on 17/05/06 for Halcyon House

This inspection was carried out on 17th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Halcyon House 14/05/08

Halcyon House 22/12/05

Halcyon House 24/05/05

Halcyon House 02/11/04

Halcyon House 11/05/04

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 Halcyon House Halcyon Road North Prospect Plymouth Devon PL2 2PJ Lead Inspector Brendan Hannon Unannounced Inspection 17th May 2006 10:00 Halcyon House DS0000003530.V291834.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 Halcyon House DS0000003530.V291834.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. Halcyon House DS0000003530.V291834.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Halcyon House Address Halcyon Road North Prospect Plymouth Devon PL2 2PJ 01752 605541 NO FAX 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) www.mencap.org.uk Royal Mencap Society Mrs Linda Jean Lewin-Smith Care Home 9 Category(ies) of Learning disability (9), Physical disability (9) registration, with number of places Halcyon House DS0000003530.V291834.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd December 2005 Brief Description of the Service: The home is located in a single storey purpose built detached building within a row of ordinary semi detached houses in the North Prospect area of central Plymouth. A full range of amenities and facilities are within walking distance though, the home has its own vehicles and the central shopping area of Plymouth is accessible by public transport. The home can accommodate up to nine residents. The home is fully accessible to residents and visitors who use wheelchairs. The home has one main entrance from which all parts of the home may be accessed. The communal areas of the home are in one half of the building and the residents’ bedroom accommodation is in the other half. There are two communal bathrooms and two communal showers. There is one double bedroom. There are two communal areas in the home. A lounge and dining area and also another lounge accessed through the lounge/ diner. There is a medium sized area of garden and patio to the rear of the building and this is fully accessible to the residents. This area can be accessed either round the side of or from the rear of the building. The service offered by the home is for men and women with a learning disability between the ages of 18 and 65. Some of the residents have substantial mobility needs and most have complex needs. The present fees range from a minimum of £415 upward depending on assessed need. The present group of residents are of a mixed range of ages and abilities but are in the main very active within the home and in the community. Halcyon House DS0000003530.V291834.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. Preparation for the inspection included analysis of the annual pre inspection questionnaire, the last two inspection reports and contacts with the home over the last 12 months. An inspection plan was developed from this information. The inspector was in the home from 9.30am to 4.15pm and the following inspection methods were used. The inspector spent time with or spoke to seven of the nine residents. The Registered Manager was spoken with at length. Three staff on duty during the inspection were spoken with and their personnel files sampled. The care of four residents was case tracked. Care plans, risk assessments, medication records, general records, health and safety records, and staff files were inspected. The whole of the building was inspected. What the service does well: The home has a stable staff team. The management and staff aim to provide a homely and comfortable place for the residents to live. The main priority for the management and staff is always the welfare and quality of life of the residents. The home can provide adequate information about the service to allow a potential new resident, with the support of their representatives, to make an informed choice whether to use the service. The resident group has been largely stable for a number of years. In general assessment of needs, care planning and individual residents risk assessments are being maintained appropriately. The delivery of care is good. There is an individually planned scheme of activity for each resident, which ensures that all the residents enjoy a good quality of life both through leisure and valued life activity, such as education courses. Residents’ personal care needs are well met by the effective staff team. The system of medication administration in the home is generally effectively managed. The residents are given good support by the staff and management to access all possible health services. Complaints are investigated appropriately using the complaints procedure and policy. The staff are trained in and are aware of adult protection issues. This knowledge keeps the residents safe. The residents benefit from a clean and adequately maintained building that has been appropriately adapted to meet their needs. Management and staff have made every effort to make the building as homely and comfortable as possible. Resident’s needs are met by enough competent, trained and vetted staff. Thorough personnel checks help to protect the vulnerable adults who live in the home. Halcyon House DS0000003530.V291834.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. Halcyon House DS0000003530.V291834.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 Halcyon House DS0000003530.V291834.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): 1,2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides adequate information about the service to allow a potential new resident, with the support of their representatives, to make an informed choice whether to use the service. EVIDENCE: Both the Service Users Guide and the homes Statement Of Purpose were available. The information in the Service User Guide was looked at in detail and a number of inaccuracies were found. For example, the new complaints procedure introduced last year is not included, it is stated that residents have a complete choice of their key worker when at most they will only play a part in the decision. The information in the Guide should be reviewed to ensure that any potential user of the service is getting up to date and accurate information. The Guide is available in a simple English and symbol format. The Registered Manager was advised to make further efforts, considering the complex needs of those who use the service, to make information in the Guide still more accessible, perhaps through the use of photographs. However the present Service Users Guide does enable potential new residents, with help from their supporters, to understand the service provided by the home and to make an informed decision as to whether to use it. No residents have moved out of, or into, the home for a number of years. There is a pre admission assessment form and procedure available to assess the needs of a potential resident to ensure that the service would be appropriate to meet their needs. Halcyon House DS0000003530.V291834.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general assessment of needs, care planning and individual residents risk assessments are being maintained appropriately. EVIDENCE: Resident’s care plans were sampled. In general they were of good quality enabling the delivery of consistent and considered support to the residents. All the residents’ had a care plan and risk assessments in place. These were being reviewed at least every six months. Each personal planning file has a list of the regular activities participated in by the resident. Residents were observed during the inspection being supported by staff to carry out personal daily living activity such as tidying their bedrooms and helping with laundry. The Registered Manager was advised to assess and document each resident’s daily living skills and then to support each resident to pursue in a planned manner as much independence in daily living activity as possible. The home has piloted a new photographic care plan to make care plan information more accessible to these residents. Some residents have significant moving and handling needs and specific risk assessments are in Halcyon House DS0000003530.V291834.R01.S.doc Version 5.2 Page 10 place to ensure residents safety. Any restrictions of personal choice have been documented to explain why they are in place. These would include hard flooring in specific residents bedrooms and listening devices to monitor specific residents at night. Due to the lack of advocates from outside the home and the complex needs of the residents the service has decided to use a person centred approach rather than introduce ‘Person Centred Planning’. The Registered Manager stated that through this method residents’ wishes will be responded to in both major life decisions and day-to-day choices. The Registered Manager has been advised to bring the care plan and risk assessments together so that this information is more easily accessible. In general care planning and risk assessment are supporting the delivery of good quality consistent care to the residents. A complete audit of the personal money held on behalf of residents by the home was carried out during the inspection. No inaccuracies were found. The residents can be assured that any of their personal money held by the home is being appropriately and safely managed. A resident has suffered a rapid deterioration in their psychological state. This deterioration is displayed as violent and aggressive outbursts towards other residents and staff. These behaviours were observed during the inspection and they are significant. Neither, this resident’s care plan or risk assessment reflect the severity of the present situation. Consistent planned support cannot be delivered based on an inaccurate care plan and risk assessments. The Registered Manager was advised that behaviours that challenge services should be care planned and risk assessed separately from the main care plan and risk assessments. Halcyon House DS0000003530.V291834.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have enough appropriate activity to ensure a reasonable quality of life while living at the home. EVIDENCE: The manager described at length the activities that were enjoyed by the residents. This information was supported by the daily activity sheet record and care plan information. Daily records for each resident cover all the positive and negative elements of the resident’s day and provided clear evidence of the quality of life enjoyed by the residents. Each resident has a completely individualised activity plan both for activities within the home and in the community, enabling the planning of a full lifestyle for each resident. Some activities participated in by residents outside the home include horse riding, music workshops, adult education and swimming. Within the home karaoke, bingo, and individualised arts and crafts, are enabled by the staff. Some of the extensive level of activity previously enjoyed by the residents has been temporarily reduced due to the present pressures on the staff team. These pressures will be reduced by an agreed increase in the staffing level. Halcyon House DS0000003530.V291834.R01.S.doc Version 5.2 Page 12 The Registered manager is aware of the need to reduce the level of overall need in the home. The communal spaces are welcoming. There was a large fish tank in the main lounge and photo boards on the walls in this room. One of these boards showed a resident enjoying activities that he had chosen to take part in on his birthday. The management and staff are doing everything possible to ensure that residents maintain the high level of activity that the residents have been used to. Halcyon House DS0000003530.V291834.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The welfare of the residents is maintained by supporting their access to health treatment, administering medication effectively and by thoroughly meeting the residents’ personal care needs. EVIDENCE: All the residents present in the home at the time of the inspection were seen. There was good observable evidence that complex personal care needs are being well met by the staff. Evidence from care planning, the observed delivery of personal care, and discussion with the Registered Manager and care staff demonstrated that care support is provided with care and consideration. The residents’ files sampled showed that health service input was actively being sought and supported by the home. A resident had recently been in hospital and the service had worked closely with the Adult Support Liaison Unit from Plymouths general hospital to try and reduce disruption to the resident during their hospital stay. The residents can be assured that their access to health care will be supported and that their personal care needs will be met by the service. It was noted that some recording of daily activity, the administration of topical creams and recording of health appointments had deteriorated due to the pressures being experienced by the service at this time. However other charts such as behaviour monitoring and epileptic seizures were being consistently Halcyon House DS0000003530.V291834.R01.S.doc Version 5.2 Page 14 completed. The registered manager was advised to ensure that all recording processes that are in use are maintained consistently. This will ensure that the health, personal care and medication administration needs of the residents will continue to be effectively met. Records, which the home has decided are necessary to supply effective care to the residents, should be kept consistently. The home uses a monitored dosage system of medication administration. There is a good medication policy written by Halcyon House. The medication procedure is a national Mencap document and it does not cover all of the areas of medication administration carried out by this service. The medication storage was clean and tidy. The Medication Administration Record was well maintained. Within controlled drug recording, signing for Medazolam quantities was at times confused. The service manages this medication under the controlled drug system and it is taken out of the home very frequently on all activities attended by the residents to which it is prescribed and then returned to storage afterward. Overall the medication system is effectively managed and the residents can be assured that their medication is being managed appropriately. Halcyon House DS0000003530.V291834.R01.S.doc Version 5.2 Page 15 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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are properly managed by the home protecting the welfare of the residents. EVIDENCE: There is a good, accessible complaints procedure. However the displayed procedure was not the procedure now in use and was not in an accessible format. The Registered Manager was advised to display the present procedure, preferably in a format that is more accessible to residents. Similarly the service User Guide did not contain the present procedure. The complaints procedure uses pre paid postcards addressed to the Mencap organisation. These postcards had previously been available in resident’s rooms but had been removed. The Registered Manager was advised to replace them so that not only residents but also relatives have them freely available without staff involvement. There has been one complaint made by one resident in the past year regarding the behaviour of another resident. This complaint was made with the support of the care staff and the following investigation upheld the complaint. The organisation is continuing to try to resolve this complaint. The documentation of the investigation could not be found during the inspection. The complaints system actively supports residents and others to access the complaints procedure. All care staff receive anti abuse training as a standard training element early in their career at the home. The home has all the appropriate anti abuse policies and procedures in place. Residents are protected from potential abuse by the awareness of staff. Halcyon House DS0000003530.V291834.R01.S.doc Version 5.2 Page 16 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): 24,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from a homely, comfortable, clean and well maintained building. EVIDENCE: The building was designed in the 1980s to meet the needs of people with significant mobility needs. However though being built for purpose it does have the potential to feel quite institutional. The management and staff have made considerable efforts through decoration and fixtures to minimise this potential atmosphere. The home was looked at closely during the inspection and only some limited damage to doors and skirting boards, due to wheelchair use, was noted. The kitchen has been redecorated in the last year, though it is largely inaccessible to wheelchair users. A new adapted bath has been fitted and the main bathroom has been redecorated. The home was clean and hygienic. Decoration in the home is generally to a good standard. The residents’ benefit from a personalised, clean and well maintained building to live in. Each bedroom has been decorated and personalised to meet the taste of the resident using it. Numerous televisions and music systems were seen in bedrooms and some residents had purchased their own furniture. Some residents also had various items of sensory equipment, such as a projector and light ball. Halcyon House DS0000003530.V291834.R01.S.doc Version 5.2 Page 17 There are accessible toilets available throughout the home. All toilets and bathroom doors have been fitted with locks that can be overridden from the outside in the event of an emergency. This facility protects both the privacy and the safety of the residents. All the residents have been offered the use of an individual lock on their bedroom door. The availability of locks supports residents independence and privacy. Some of the residents have chosen to use a key to their bedroom. Others have chosen not to use a key or their risk assessment has clearly shown that holding a key would create an unreasonable risk for them. Halcyon House DS0000003530.V291834.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): 32,33,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by enough competent, qualified, properly checked and trained staff. EVIDENCE: The manager stated that there is always an adequate number of staff on duty to meet the needs of the residents and the rota record evidenced this. The home has between three and four care staff throughout the day. Funding for additional staffing has been obtained to meet the present increased levels of need. Further funding is being pursued. It is hoped that with these increased levels of staffing some of the pressures felt by residents can be reduced. There was evidence from activity records and from staff interview that residents’ previously high levels of activity had temporarily reduced. It is hoped that with the new increased staffing level the previous level of external activity will resume. Where residents’ behaviours have changed and caused new staff training needs the registered manager was advised to plan to meet these as quickly as possible. Staff training / personnel files and the Pre Inspection Questionnaire were sampled, and staff were asked about their training. All basic training such as First Aid and Moving and Handling was up to date. Approximately half of the staff team are NVQ2 in care or above qualified. If all those engaged on an NVQ complete their course then approximately 90 of the care staff team will be Halcyon House DS0000003530.V291834.R01.S.doc Version 5.2 Page 19 qualified. A thorough training programme is run by the organisation to ensure that the level of qualification of the staff in the home is maintained and that residents’ needs are therefore fully met by skilled staff. The organisation is also training all new staff in the Learning Disability Award Framework as part of their induction. This qualification gives staff specific skills to work with people with a learning disability. This induction training then forms part of an NVQ2 and enables staff to meet resident’s needs soon after beginning work at the home. The Registered Manager stated that all the staff have Criminal Records Bureau clearances in place. Personnel records were available in the home to verify the recruitment procedure carried out for each member of staff. A programme of six individual staff supervision sessions is carried out per year. This monitoring will help to ensure that good quality staff practice continues to be delivered to the residents. Halcyon House DS0000003530.V291834.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): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home ensures that good quality care is consistently delivered to meet the residents’ needs. EVIDENCE: The Registered Manager, Linda Lewin-Smith, became manager at the home in 1992. She has obtained a Diploma in Management Studies, and City and Guilds Foundation, and Advanced Care Management qualifications equivalent to the Registered Managers Award. She is following an NVQ4 in care and hopes to finish by the end of 2006. The organisation has developed a quality assurance system that is focussed on residents concerns. The system is based on questionnaires and therefore most residents need help to fill these out. However such difficulties do not stop the residents engaging in this process. The last quality assurance round also received responses from staff and nine relatives. Relatives’ views of the service ranged from good to very good. Halcyon House DS0000003530.V291834.R01.S.doc Version 5.2 Page 21 Comprehensive safety checks have been carried out during the last year, as noted in the annual pre inspection questionnaire, including gas appliances, Legionella, and electrical equipment. All hot water outlets have been fitted with water temperature control valves. Most radiators available to residents have been covered or a risk assessment is in place to demonstrate that a cover is not necessary at this time. These measures protect residents from the danger of scalds and burns. Good management of health and safety protects the welfare of the residents. Halcyon House DS0000003530.V291834.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 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 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 2 X 3 X 3 X X 3 X Halcyon House DS0000003530.V291834.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. Standard Regulation Requirement Timescale for action 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 YA1 YA20 Good Practice Recommendations The Service User Guide should be reviewed to ensure that it is kept accurate. The medication procedure should be comprehensive covering all areas of medication administration carried out by the service i.e. Management of Controlled drugs. The signing record for Controlled Drugs when taken out and then returned from an activity should be kept consistently. When creams are to be signed for as administered by staff this record should be kept comprehensively. Halcyon House DS0000003530.V291834.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Halcyon House DS0000003530.V291834.R01.S.doc Version 5.2 Page 25 - 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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