Inspection on 24/07/06 for Hayling Road

This inspection was carried out on 24th July 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hayling Road 13/12/05

Hayling Road 19/04/05

Hayling Road 10/10/04

Hayling Road 28/06/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hayling Road 34 Hayling Road Sale Manchester M33 6JN Lead Inspector Michelle Moss Key Unannounced Inspection 24th July 2006 10:15 Hayling Road DS0000005611.V302032.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 Hayling Road DS0000005611.V302032.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. Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hayling Road Address 34 Hayling Road Sale Manchester M33 6JN 0161 973 4306 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) Stockdales of Sale, Altrincham & District Ltd Ms Laura Jayne Aston Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All six service users have a learning disability and may also have an associated physical disability. Within the overall maximum number (6) one named individual who is out of category by reason of age can be accommodated 13th December 2005 Date of last inspection Brief Description of the Service: Hayling Road is a care home providing long-term personal care and accommodation for 6 young adults with complex needs (physical & learning disabilities). It is managed by Stockdales of Sale, Altrincham and District Limited, which is a charitable organisation. The home is located in an established residential area in Sale, close to shops, bus and train routes and other amenities. The home was opened in 1997 and consists of a two-storey building. The communal areas are located on the ground floor and include a lounge, kitchen, dining area and conservatory. Two of the bedrooms are situated on the ground floor with the remaining four on the first floor. All the homes bedrooms are single. There are gardens to front and rear of the property, which are well maintained. The weekly fees changed at time of this inspection were £968.39 – £1,178.35 approx. The home’s inspection reports are made available to residents’, families and professional on request. A copy of the home’s Statement of Purpose and Service Users Guide is always made available to read at the home. Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector went to the home without telling anyone she was going to visit on the morning of Monday 24th July 2006. The inspector spent 2 hours visiting the home and had also previously spent one hour looking at staff records at the organisation’s head office. All residents were sent a questionnaire. With the help of staff 2 of the questionnaires were returned. During the visit to the home the inspector also: • Met and talked with residents • Spoke with the staff on duty • Looked at some residents care plan records. • Looked around the home. • Watched how the residents and staff got a long together. To help the inspector to write this report the home provided a self-assessment report /questionnaire, which was completed by the manager and was received by the Commission 23 June 2006. This report has also taken into account other information, which the Commission knew about the home. There were some important things the inspector wanted to find out about the care given by the home. These were: • • • • How the health needs of residents were met. How the personal care needs of residents were met. How the staff helped to kept residents safe and promoted community involvement. How the home respected the resident’s rights, diversity and identity. The term of address preferred by the users of the service was confirmed as “residents”. What the service does well: These are some of the things that were found to be good about the home from information received in questionnaires completed by residents. • The residents indicated they received the care and support they needed. • The residents felt the staff listened and acted on what they indicated through body language. During the visit to the home evidence was seen to support this was happening in practice. • The residents indicated that they received the medical support they needed The information provided through the questionnaires showed that residents felt cared for, their health needs met and felt staff valued their contribution in decision making. Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 6 The staff had been trained in meeting the care needs of residents. This helped to keep residents healthy and that their welfare was safeguarded. Residents were supported by the staff team to go on holiday at least once a year and to complete a range of community-based activities. This meant residents were being supported to be inclusive of their community and that activities undertaken took into account their diverse needs. The residents were seen to be treated as individuals and the staff team provided care that reflected the residents’ rights and preserved their dignity and privacy. This meant that the staff team understood the importance of respecting and seeing the house as the residents’ home. The home was nicely decorated and fitted with aids and equipment that assisted the residents to remain safe and healthy. This meant residents benefited from having a homely environment, which promoted their overall wellbeing. The staff rotas showed that the staffing was set at a level that met the needs of the residents. This showed that there were enough staff to make sure residents were kept safe and adequately supported. Information seen about the support of staff showed they were themselves well supported by their manager and encouraged to develop their skills to better meet residents social and health needs. When the home recruited staff they made sure the person was suitably experienced, that checks were completed that showed they were medically fit and suitable to work with vulnerable adults. This meant staff members that were both adequately skilled and assessed as suitable to work with people with disabilities. What has improved since the last inspection? What they could do better: From examining medication charts it was found that on occasions staff were not signing to confirm they had given a resident their medication. Also, the times of different medication needed to be rechecked. By making sure Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 7 medication records were signed correctly and medication given at the right times would mean the health of residents will be better safeguarded. The care plans needed to be better monitored to make sure all parts of the plan were the same so that all staff followed the right guidelines on how best to keep a resident healthy and safe. The home needed to have more details in the care plan about the cultural and spiritual needs of the residents and how the home should respect each resident’s beliefs. By having better information the staff would have more understanding about how best to meet the diverse needs of residents. 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. Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 8 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 Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents changing needs were assessed through a care planning system. EVIDENCE: The home had a static resident group, which had resulted in the home not receiving any new admissions for sometime. As part of the ongoing care of residents periodic reviews were completed on the assessment of needs. Hayling Road DS0000005611.V302032.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, & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefited from having an informative care plan that highlighted their needs. However, the positive aspect of the plan was compromised by the inconsistency between the assessment of needs and changes in the care plan. Also, there was insufficient information about meeting the diverse needs of residents. These weaknesses had the potential to have an adverse affect on the welfare and health of individual resident’s. EVIDENCE: A random sample of care plans were examined. The plans covered a number of key areas relating to care. These included dietary needs, health, social and emotional well being and preferred methods of communication. They also highlighted daily routines and interests. This extended to likes and dislikes, details about activities, social needs and relationships. A chart was set up that mapped all the various activities a resident was doing on a daily basis. This was informative to determine the range of activities completed by residents. However, on case tracking two residents care plans and their related needs Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 11 assessments, some concerns were raised. This related to the home not removing old care plans when new ones were introduced. Also, that the assessment of needs were not being updated to reflect the changes in instruction on how best to meet the needs of the resident. For example, in the plan for a resident who had required an updated eating and drinking assessment after being in hospital with suspected Pneumonia caused by possible aspiration, the new guidelines were detailed and set new protocols on food consistency e.g. all blended. Yet the assessment of needs still indicated mashed / blended and no reference was made to the importance of the resident being fully supervised. Despite this the assessment of needs about the resident’s eating and drinking was reviewed in July 2006, and signed off as still current. The home needed to undertake an urgent review of the care plan to ensure all parts were up to date and instructions provided to staff accurate to reflect current needs. Another shortfall found in the plan was demonstrating how the home met the resident’s diverse needs. For example, religious beliefs, age and social inclusion. The initial assessment indicated the resident’s religion only. It did not inform if a resident chose to practice their religion or not. From speaking with staff about diversity, they could identify things they did which respected individual identity and doing age appropriate activities. This included resident’s choosing their own activities and hobbies. It was confirmed by the deputy manager that the home was working towards person centred planning. It was anticipated that the diversity of residents would be better evidenced under the new care plan. Hayling Road DS0000005611.V302032.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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents were able to exercise their rights, including in general their diverse needs being valued by Hayling Road. Also, the home enabled residents to choose their own daily routines, maintain family links and have a varied and nutritious diet. EVIDENCE: At the time of the visit the residents were all being supported through a social therapy session, which included having a BBQ. Everyone was seen to be enjoying themselves. It was highlighted that the social therapy had become increasingly flexible so that residents could access more varied activities and experience difference life skills. This included an increase in the staff at the social therapy service. From talking with staff they were familiar with the various ways diversity should be promoted. By identifying resident’s likes and dislikes in areas such as planning holidays and social outings. This included recognising their disability and how this affected them and reflecting personal preferences. For Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 13 example the residents favourite football team or music group and planning trips that best met the resident needs. The home positively encouraged family links. Families were consulted about the home through the organisation’s annual Quality Assurance survey and general contact with the home and planned social events. A monitoring chart for activities had been introduced. This showed that residents benefited from a variety of different activities that reflected their personal preferences. A number of sources of information were seen about offering residents healthy food and how the residents’ nutritional needs were assessed. This included recorded facts associated with eating and drinking disorders and the safeguards that were required to be in place to ensure a resident’s health and wellbeing was not compromised. A range of eating aids were seen to be used by the staff that enabled residents to maintain their independence whilst eating and drinking. For example providing special spoons, cups and plates. Throughout the inspection evidence could be seen that demonstrated the outcomes for residents lifestyle was positively promoted by the home. This included staff communicating with residents in a way in which they were able to positively contribute to make informed decisions. This extended to staff understanding the different body gestures made by residents to indicate their personal preferences. Hayling Road DS0000005611.V302032.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 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents were having their personal and healthcare needs met by the home. This included ensuring that good arrangements were in place for safeguarding residents’ general health and welfare. However, these positive outcomes were compromised by the continual weaknesses found in the management of medication, which had the potential to have an adverse affect on the health of a resident. EVIDENCE: The home supported residents with complex physical and health needs. Their care plans were a vital source of information about how their needs were required to be met by the staff team. The home was found to be well equipped with aids that ensured the health of residents could be safeguarded. These were fitted in a way that made them easy to access, this was done in a non-clinical way which did not impact of the homely surroundings. The approach of blending specialised equipment into the structural part of the building was seen to be done extremely well. Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 15 The daily care plans examined gave a detailed record of the health needs of the residents including the joint care between the home and health professionals to ensure the residents health needs were appropriately met. The home had introduced a health summary care plan, which was designed to go with the resident if, or when, they required emergency medical treatment. On examining a sample of these records it was noted they were person centred, provided a picture of the residents and explained to professionals about things, which were important to the welfare of the residents. For example, the way the resident communicated, understanding their emotional well being by informing the hospital of the resident’s fears to injections. This was a commendable piece of work. The only recommendation made was about ensuring the medication list was checked regularly so that the information provided to a hospital would not be out of date or add a standard statement to refer to the resident’s medication chart. The medication records of all residents were seen. This was in response to previous inspection findings where minor shortfalls in medication were noted. In the majority of cases the records were maintained well with an accurate audit trail seen. However, there were some concerns, which were discussed with the deputy manager. There were a number of missing signatures on the records relating to the month on July. Furthermore, an instruction given by a health professional regarding two medications (Epilm & Peptac) was questioned because they were known to interact and required at least 2-hours gap between each other. On the medication chart it was noted there was only a one hour gap (8am & 9am). No additional notes had been made by staff to demonstrate they had ensured the two-hour gap was met. A system for monitoring medication records and practices in administering medication were required to avoid any adverse affects on the health of the residents. Hayling Road DS0000005611.V302032.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Residents’ views were raised through their parents with systems in place where concerns would be listened to and acted on. Policies and procedures and training programmes were in place, which the staff were required to attend and adhere to. This ensured that residents were safeguarded from all forms of abuse. EVIDENCE: Information received from the provider via a pre inspection questionnaire confirmed the home had not had any complaints made by either the residents or others. The information provided by the home further confirmed that all staff members were receiving training in vulnerable adult protection and that recruitment of staff was done with all appropriate checks including completing POVA firsts and CRB checks. Information received from two residents through a questionnaire indicated they were provided with pictorial aids plus easier to understand information about how they could raise a concern. Overall their parents would advocate on their behalf if any concerns were raised. A visit was completed to the head office in June 2006 where a sample of staff files were examined. These were all found to have the appropriate checks in place that confirmed prospective staff members were checked for their suitability to work with vulnerable adults. Hayling Road DS0000005611.V302032.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents lived in a homely, comfortable and safe environment. Their health and wellbeing was being protected by the design of the premises and by having a good state of cleanliness. EVIDENCE: The residents lived in homely and comfortable surroundings, which had been sufficiently adapted to reflect their needs. This had included last year the fitting of overhead tracking in all parts of the home. This was done extremely well including blending the tracking system into the décor. Residents were actively encouraged to personalise bedrooms. For example, having memorabilia of a favourite football team. Information received via a questionnaire by the provider confirmed that health and safety checks and testing were completed regularly within the home. Furthermore the health and safety records examined during the site visit were found overall to be well maintained. Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 18 The staff had worked with the residents to develop the garden to make it more accessible and sensory. This had resulted in all residents being able to access the garden and get enjoyment from the various smells and touch of plants. Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were good practices in staff training and staffing levels which reflected the needs of the residents. This meant that there were adequate staff to make sure residents were well cared for and their welfare protected. EVIDENCE: The numbers of staff on duty were seen to meet the needs of residents well. The relationship between the residents and staff was observed as very positive. The staff members were seen to be skilled in effective communication with residents. This meant that the residents could be actively involved in their home and about their daily activities. From the sample of staff records examined they showed that the staff team were supported through regular supervision. Training was well delivered by the organisation. The range of training included: Child Protection, Loss & Bereavement, First Aid. Person Centred Planning, Supervision for management, Health & Safety and NVQ of which over 85 of staff had achieved or held an equivalent qualification. Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 20 A sample of staff files were examined during a visit to the organisations head office in June 2006. The findings of visit concluded that the recruitment of new staff was found to be completed in a rigorous process that ensure the all prospective staff were suitable to work with vulnerable adults. Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected 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. Overall, areas of management and health and safety were good. Also, areas of quality assurance systems and internal monitoring of care provided were good and demonstrated that the service was sufficiently self-assessing the quality of care. EVIDENCE: The organisation was completing good internal monitoring of the service. This included the manager doing checks on records within the home and the chief executive and the responsible individual completing unannounced checks on the running of the home. The assistant manager was found to be familiar with the needs of residents, all of which were demonstrated throughout the inspection. The relationship between the staff and the residents was seen to be respectful and the staff responded sensitively to the changing needs of residents. Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 22 Each year the organisation completed an annual survey where families and other stakeholders were asked to comment on the quality of the service. The findings of the 2005/06 surveys were examined. The findings indicated that areas of care, friendliness, meals and staffing were all overall rated as excellent. From a random sample of records examined it was confirmed that the home was keeping good records on fire safety and other health and safety checks all of which were overall monitored on a regular basis in line with good practices. Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 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 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000005611.V302032.R01.S.doc 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hayling Road Score 3 3 2 X 3 X 3 X X 3 X Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 Requirement The medication record must provide a full audit trail of all medication administered by staff. Also, medication administered must be completed in accordance with instructions provided by health professionals. Care plans and needs assessments must be kept under review and revised at any time when it is necessary to do so, having regard to any change of circumstances / needs. This process should include avoiding any inconsistency in information, which could have an adverse affect on the health of a resident. Timescale for action 30/08/06 2 YA6 15 30/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000005611.V302032.R01.S.doc Version 5.2 Page 25 Hayling Road 1 Standard YA6 It is recommended that the home add more details within the care plan about the diversity of residents. This includes the cultural and spiritual needs of individual resident’s, which will demonstrate how the home should respect the resident’s beliefs. Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Hayling Road DS0000005611.V302032.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!