Inspection on 16/01/06 for Hartington House

This inspection was carried out on 16th January 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hartington House 26/09/07

Hartington House 02/08/06

Hartington House 16/08/05

Hartington House 28/02/05

Hartington House 29/09/04

Hartington House 11/03/04

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

CARE HOME ADULTS 18-65 Hartington House 14 Hartington Road Heaton Bolton Lancashire BL1 4DP Lead Inspector Lucy Burgess Unannounced Inspection 17th January 2006 09:30 Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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 Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hartington House Address 14 Hartington Road Heaton Bolton Lancashire BL1 4DP 01204 410854 01204 493126 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) Perpetual (Bolton) Ltd Mrs Tricia Varey Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 16th August 2005 Date of last inspection Brief Description of the Service: Hartington House is a small care home providing residential care for up to 5 people with mental health needs. The home is part of a small group of two homes (the other being Somerset House). Both homes share the same staff team and are situated near to each other in the residential area of Heaton in Bolton. There is a small office at Hartington House, although the main office base for the two homes is at Somerset House. A local company, Perpetual Care, owns the home, with the day-to-day management carried out by the Registered Manger. Hartington House is an end terrace house, consisting of 5 single bedrooms and communal areas. The house is close to a main road leading into Bolton town centre and is accessible to local amenities and public transport. Residents are generally of a younger age range at Hartington House than those at Somerset House. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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 for a period of 6 hours. The inspector took the opportunity to look round the home, view records as well as talk with residents and staff. Discussion and feedback was also held with the senior on duty. The home is registered to provide accommodation for up to 5 people with mental health needs. At the time of the inspection there were no vacancies. What the service does well: What has improved since the last inspection? Staff training has taken place covering mental health needs, the law as well as from a service user view. Feedback about the courses were positive. Staff felt this gave them some insight into what mental health needs are and the support to be provided. On going redecoration has taken place within the home enhancing the environment. The manager is aware that further work is needed and is making arrangements for this to happen. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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 Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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 The system of assessing prospective residents as well as spending time with them prior to admission gives an assurance that a resident will only be admitted if the home can meet their needs. EVIDENCE: Documentation was seen for the newest resident. Comprehensive information, assessments and mental health reviews had been carried out by the relevant health and social care professionals clearly outlining the emotional, physical and mental health needs of the individual as well as identifying areas of risk. These documents had been received by the home prior to the placement being formally agreed. This enabled the manager to make an informed decision about whether needs could be met at the home. Prior to the placement being agreed opportunities were made available for the service user to visit the home as well as overnight stays. Several visits were made prior to moving in, these enabled the service user to meet and spend time with other residents and staff getting to know them. Following the trial visits formal agreements were made between the service user, mental health professionals and the home ensuring the placement could meet the identified needs. This would be reviewed again over a period of time ensuring the service user had settled. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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 and 9 Residents care plans and risk assessments do not fully reflect the support needed. These should be developed ensuring residents health and well being is maintained and encouragement is provided where necessary. EVIDENCE: Each of the residents has their own care plan and risk assessments, which are drawn up by their key workers. Information was seen for the newest resident. This included detailed assessments, a background history and minutes from previous mental health reviews. These documents provided staff with comprehensive information in relation to the needs and risks related to the individual. Staff had also gathered further information during the initial visits and over night stays made prior to the placement being made enabling all parties to review the suitability of the placement and whether the identified needs could be met. From the information seen a number of areas required monitoring, however no care plan or specific risk assessments had been placed on file. Action detailed following a mental health review referred to the homes own risk assessment Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 Page 10 with regards to personal safety within the community however this could not be found. Due to the level of need detailed within the reports information and risk assessments need to be developed ensuring that needs are met and the necessary support provided. Plans of care were in place for other residents. These had recently been reviewed. Information includes details about their mental health needs and behaviours, daily routines and professional involvement. Goals have also been identified within the care plan outlining individual long and short-term aims. It is suggested that plans are signed by the residents to evidence their involvement and agreement. Formal reviews continue to be held with relevant health care professionals so that mental health needs of residents are monitored. Minutes of these meetings are held on file. Additional support and advice is also provided form social workers and community psychiatric nurses (CPN) should this be needed. Daily evaluation sheets continue to be completed by the staff following each shift. These include details of administration of medication, meals taken, activities and any additional information i.e. appointments, incidents etc. In the main these had been completed however on some days there were gaps, staff should ensure that all information is recorded so that on-going monitoring is provided. As previously identified one of the residents has a history of self-neglect and poor diet. A risk assessment had been completed and identified that this area needed to be monitored, a balanced diet was to be offered and weight needed to be checked on a weekly basis. Although some information regarding diet intake was recorded on the evaluation sheets this was still very limited as the resident spends the majority of his time away from the home at the other unit. A system should be developed so that information is recorded and monitored ensuring his physical and mental health needs are met and where necessary appropriate action taken to address any concerns identified. As previously identified, it is difficult to gather structured feedback from residents about their satisfaction in relation to living at Hartington House. From general discussions and observations it was clear that residents enjoy the company of staff. Interactions with staff were seen to be open and friendly. Staff were found to have a good awareness of individual needs. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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, 15 and 17 Routines vary depending on individual choices and preferences. Residents access the local and wider community enabling them to lead valued lives, develop skills and increase their independence. Support is offered where required. Residents maintain contact with family and friends and open visiting is encouraged. A variety of meals are provided. Consideration should be given to the provision of items depending on the dietary needs of service users. EVIDENCE: The home is a small property situated within a residential area and is indistinguishable from those around it. It is easily accessible to Bolton town centre and is situated close to the main bus route. The home also has the use of a vehicle, which is the preferred form of transport for the residents. Activities are supported for those who require additional support. Routines at the home vary depending on individual wishes and motivational levels with individuals rising and retiring as they wish. Residents pursue activities both in and away from the home and staff offer encouragement in Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 Page 12 maintaining their independent living skills. Individuals continue to have regular access to community facilities accessing local shops, take-away etc. Residents also have a variety of items such as televisions, videos and stereos, which they can relax and listen to. At present residents generally choose not to pursue formal courses or therapeutic employment. Staff continue the practice of giving mail to the residents unopened, however support is offered with those items needing a response etc. Residents also have a key for their own room, however are not routinely given a key to the front door due to areas of risk. Generally the house is always occupied. Residents continue to maintain contact with family and friends. Visits take place both at the home or with residents visiting family members. Contact is made on a regular basis. Due to the needs of some of the residents specific arrangements are in place with regards to home visits, these are monitored and reviewed. In relation to meals, residents are encouraged to prepare there own breakfast and lunch, however the evening meal is prepared by staff. During the visit the weekly shopping was purchased. Items included fresh and frozen fruit and vegetable, cakes, yogurts, ready meals and fresh meat. Halal food was also available as one of the residents follows a halal/vegetarian diet. As already identified further in the report, one resident has a history of nutritional and weight problems. Therefore accurate records need to be maintained with regards to his diet and weight records. Consideration should also be given to the purchasing of low fat foods, whilst this may benefit those wishing to follow a healthy diet plan this may be the preferred option for those with specific dietary needs. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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 and 20 Residents’ mental health needs are consistently met. Additional support is required in relation to encouraging service users to maintain their personal care ensuring their well-being is maintained. Relationships with mental health professionals are effective and provide positive support networks for the residents ensuring their health needs are promoted. The medication system was found to be safe and staff have completed training ensuring residents are protected and practice is safe, minor improvements were needed to the records. EVIDENCE: Information is held in relation to the mental and physical health needs of residents. Health care professionals are accessed for additional support and advise ensuring sufficient support and monitoring is provided in meeting the needs of residents. Formal reviews as required under the discharge programmes are held and discussion includes the residents’ stability, progress or concerns in relation to their mental health. Further information is also recorded within the care plans outlining the specific support needs of individuals and how they are to be met giving clear directions to those offering support. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 Page 14 Records are made of all professional visits and appointments, which include community psychiatric nurses, GP, hospital etc. Each resident has access to all NHS entitlements as and when they are needed. Support is offered for appointments. Staff provide personal care support in varying degrees. This is very much dependent on individual needs. In the main residents are prompted in maintaining their own personal care, however one resident is assisted when bathing. It was noted that two of the residents spoken with had a slight odour. Staff outlined the support provided however at times there were difficulties in motivating the residents in meeting their personal care needs. The team should look at ways in which they can encourage and promote the resident in developing this area. Bathing and toileting facilities are provided on the ground and first and are easily accessible to each of the residents. Daily evaluation sheets are completed for each of the residents, which includes the monitoring of their diet. Individual records are also made of their weights. On examination of the records it was found that residents were having significant loses or gains each month. For example one resident had gained 5 pounds in November, lost 7 pounds in December, gained 14 pounds at the beginning of January however the following week had lost 14 pounds. Action should be taken to either repair or replace the scales so that accurate records can be made. Where on going changes are noted in weight records appropriate action should be taken to address this and advice sought from relevant health professionals. As already stated it was found that all milk stocks were virtually fat free milk. Consideration and consultation also needs to be given with regards to the milk provided. Whilst this may be for the benefit for those residents who wish to follow a diet/healthy eating programme this does not apply to all. Information recorded for one resident showed that there was a history of self-neglect and poor diet his daily intake is to be monitored ensuring her receives a balanced and healthy nutritious diet. The medication system was looked at. An audit of the system had been carried out. It was found that several gaps where found to the MARS sheets therefore providing incomplete information. Medication held within the home is stored safely along with individual records. Minor improvements were needed to the records with regards to changes made to any prescribed medication stating date of change, by whom and then signed. Where mediation is held by the home but administered by other health professionals this too should be stated on the MAR sheet. At present the home does not hold any controlled drugs. Staff have received the relevant training required. 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. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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 and 23 Systems were in place with regards to the investigation of complaints and adult protection issues, ensuring that residents were listened to and protected. EVIDENCE: Clear policies and procedures are in place covering these standards. A copy of the Local Authorities Vulnerable Adults procedure has been accessed. The team have some knowledge in relation to the procedure to follow and training has been completed. Several members of the team still require training in this area. Recent issues, which have arisen have been dealt with in line with the home’s policies and procedures. The Manager has ensured information has been recorded and action taken where necessary. All necessary personnel have also been informed and kept up to date. No complaints have been raised with the CSCI. The home also has further written policies and procedures for adult protection. These include dealing with whistle blowing, aggression, service users finances and missing persons. All staff have a Criminal Record Check in place. Clear procedures are in place for handling residents’ money. Records are made of all transactions as well as receipts being held. A random sample was checked, an error was found to the records for one individual. Staff must ensure that accurate records are maintained. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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 Hartington House continues to provide a comfortable homely environment. Further redecoration and refurbishment is still needed and would enhance the environment for the people living there. EVIDENCE: Hartington House is a small home set within a residential area of Bolton. Accommodation consists of 2 lounges, one of which is the staff sleep-in room, a dining kitchen, 2 bathrooms and 5 single bedrooms. There is also a staff office on the second floor. Those wishing to are able to personalise their room to their liking. On-going work is being carried out at the home. Recent work has included new floor covering for the halls and stairs, new lock fitted to room 1 and improvements to the 1st floor bathroom, however this has caused some damage to the hall and stairs, which too will require redecoration. Further work is required to the closing devise to the sleep-in lounge, which needs repairing or replacing, paintwork to both inside and outside of the property, light shade to 1st floor bath and window blind for privacy and curtains re-hung in room 4. It is also suggested that the old toilet and shower mats in the ground floor bathroom are replaced due to health and safety. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 Page 17 Aids and adaptations have been fitted outside the front door and to the stairs to aid the mobility of one of the service users. The home has also accessed a wheelchair, which would be used for longer journeys. Staff undertaken most of the domestic tasks however where possible residents are also encouraged to assist. Separate hand-washing facilities are provided in the basement laundry and kitchen to prevent the spread of cross infection. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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 and 35 Staff at the home are in sufficient numbers to meet the needs of residents. On going training is provided to equip staff with the knowledge and skills needed in meeting the needs of service users. EVIDENCE: Staff at Hartington House comprises of the manager, senior carers, carers and casual staff. Levels have recently been increased so that sufficient staff are available to meet the particular needs of the service users. This enables staff to provide 1-2-1 or group support during the day so that service users can join in activities. Night cover has also been increased and consists of 2 sleep-in staff. Consideration should be given however to the sleep arrangements at the home as currently both staff members are sharing a room. Staff at Hartington House also work at Somerset House, which is where the main office is situated. Individual staff files are held at Somerset House therefore were not available for inspection. This standard will therefore be addressed at the next inspection at Somerset House. Training has been provided to member of the team, this has included TCI, which is in relation to behaviour management and intervention and 1st aid. Courses have also been held in relation to mental health needs and relevant legislation as well as what it’s like to have mental health problems from a Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 Page 19 service user perspective. Staff feedback regarding the courses was very positive and gave then a good overview of individual needs and behaviours. Further training is needed for some members of the team in Vulnerable Adult, 1st aid, mental health and TCI. Communication was said to be good. As the team is relatively small staff have the opportunity to work with each other during the week. Staff spoken with were positive about their role and expressed that they ‘enjoyed their work’, ‘brilliant group of people’ and ‘I didn’t think I could like a job so much’. Staff felt supported by the manager and felt they could approach her if they had any issues or concerns. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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 overall management of the home is consistent and reliable for the people living there. Systems are in place for the reviewing of the service provision. A report regarding quality assurance should be developed and shared with all parties. Satisfactory arrangements are in place with regards to providing a safe, well maintained home so that residents and staff are safe from harm. EVIDENCE: The Residential Manager is responsible for the day-to-day management of both units, Hartington House and Somerset House. Training with regards to the Registered Managers Award and NVQ level 4 have previously been completed. Other training courses related to the needs of service users have also been completed ensuring that her practice is up-to-date. The owner of the organisation supports the manager in her role. Although there is no formal system in place for reporting feedback from stakeholders with regards to the overall service provided information is Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 Page 21 gathered in a number of ways. Residents have regular contact with the manager and feel able to discuss any matters or ideas they have. Residents were said to prefer the informality of 1-2-1 discussions as opposed to meetings. As the manager spends time in each of the units this enables her to speak with each resident on an on-going basis. Feedback is also sought from the staff during the periodic team meetings and supervisions. Additional comments are also received during the residents review meetings, which involve health and social care professionals. It is suggested that a report in respect of all quality reviews is written outlining the development plan for the home and made available to all interested parties. Up to date certificates were seen for the 5-year electric checks, gas, fire appliances and alarm, emergency lighting and small appliances. Regular inhouse checks are also made with regards to sounding the fire alarms, checking means of escape. Drills are undertaken with each new staff members however no recent drill has been held with the service users. It is advised that this is undertaken. Records are also held in relation to water temperature and fridge and freezer temperature. On examination of the water temperatures information only stated that it was hot. The manager must ensure that records are made of the temperatures from all outlets used by the service users. The temperature must be maintained at 43oC. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 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 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 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 3 X 2 X X 2 X Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 15 Requirement That care plans include all information as outlined within the report in relation to the care and support needs of service users That action identified within the risk assessments is followed up and evidence of monitoring is recorded and place on file That service users are consulted with regards to the type of milk provided particularly where individuals have identified dietary needs. That consideration is given to how service users can be effectively support in meeting their personal care needs fully. That accurate records are made with regards to individual weights and action taken where particular needs have been identified That codes are entered on the medication sheets where medication has been refused or administered by another person i.e. nurse (previous requirement of 30.0.05) That changes made to the DS0000009315.V265737.R01.S.doc Timescale for action 30/03/06 2. YA9 13 30/03/06 3. YA17 16 28/02/06 4. YA18 12 30/03/06 5. YA19 17 28/02/06 6. YA20 13 28/02/06 7. YA20 13 28/02/06 Page 24 Hartington House Version 5.1 8. 9. 10. YA23 YA24 YA34 17 23 19 11. YA35 18 12. 13. YA42 YA42 23 23 prescribed medication is dated and signed evidencing when the change was made and with whom it was agreed. That accurate records are maintained with regards to residents’ money. That work required in relation to the environment are addressed as outlined within the report. That information required under Regulation in relation to staff is held on file prior to commencing employment. (previous timescale of 31 October 2005 not met) That training identified within the report is provided ensuring that all staff have completed such courses That an up to date fire drill is undertaken involving all service users and staff. That water temperature are recorded ensuring that they are maintained at 43oC. 28/02/06 30/03/06 30/03/06 30/03/06 28/02/06 28/02/06 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. 2. 3. 4. 5. Refer to Standard YA7 YA19 YA24 YA32 YA39 Good Practice Recommendations That where possible residents are encouraged to sign their care plan to evidence their involvement That the homes scales used for weighing service users are repaired or replaced. That the curtains are re-hung in bedrooms 4. That consideration is given to the sleep-in arrangements at the home. That a report in respect of all quality reviews is written outlining the development plan for the home and made available to all interested parties. Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 Page 25 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 Hartington House DS0000009315.V265737.R01.S.doc Version 5.1 Page 26 - 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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