Inspection on 12/03/08 for Healy House (Burnley)

This inspection was carried out on 12th March 2008.

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 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

Healy House (Burnley) 02/08/07

Healy House (Burnley) 14/12/06

Healy House (Burnley) 16/05/06

Healy House (Burnley) 24/11/05

Healy House (Burnley) 04/05/05

Healy House (Burnley) 14/12/04

Healy House (Burnley) 28/07/04

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

CARE HOME ADULTS 18-65 Healy House (Burnley) 11 Ormerod Road Burnley Lancashire BB11 2RU Lead Inspector Mr Jeff Pearson Unannounced Inspection 12th March 2008 9:30 Healy House (Burnley) DS0000009528.V360699.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 Healy House (Burnley) DS0000009528.V360699.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. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Healy House (Burnley) Address 11 Ormerod Road Burnley Lancashire BB11 2RU 01282 838845 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) Mrs Bridget Mary Healy Vacant post Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2007 Brief Description of the Service: Healy House is part of Healy Care Burnley, which includes three separate terraced properties. The properties are situated on the same road, in what is primarily a residential area. The home is close to shops and local resources. The accommodation available is homely and mostly domestic in style. The home has a dining kitchen and a communal lounge. A room is provided for people who smoke. There is one shared and three single bedrooms; one of the single rooms has an en-suite facility. There is a large yard to the rear of the home. Staff are on duty to provide support 24 hours per day. Transport is available to enable service users to visit relatives, take short trips, including outings within the local area and further a field. At the time of this inspection visit, the range of fees charged were between £351 and £950 per week, there were voluntary optional charges for entertainment and transport. The home had a Statement of Purpose and Service User Guide providing information about the support and services available. Copies of this information and the most recent inspection report were available in the homes office; this should help people make an informed choice about accepting placement at Healy House. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means people using this service experience adequate quality outcomes. A key unannounced inspection, which included a visit to the home, was conducted at Healy House on the 12th March 2008. The visit took over 9 hours and was carried out over one day by one inspector. A random unannounced inspection had previously been carried out at the home on 01/10/07. A letter following this inspection will be made available to members of the public or other enquirers on request from the Commission. The files/records of three people using the service were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living at the home. Discussion took place with people using the service, acting manager and staff. Various documents, including policies, procedures and records were looked at. Some of the accommodation and facilities were viewed. At the time of this inspection visit there were 4 people living in the home. What the service does well: People living at Healy House were having some say in who worked at the home, by helping interview new staff. Contact with relatives and friends was good, people said they were keeping in touch with their parents and children. Everyone was happy with the meals provided, people were involved with choosing menus and cooking. “The food is always good,” commented one person. House meetings were still being held each week, so people could be asked about things which affected them. One person explained, “We voice our opinions, the opportunities there to do it,” People living at Healy House were being involved with some day-to-day matters, such as choosing activities and how to spend their time. They were being encouraged to gain self-help skills, by helping out around the home. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 6 People were being supported to take an interest in their appearance, hairdressing and clothing. Support was being given with healthcare and appointments. What has improved since the last inspection? There had been a lot of improvements since the last key (main) inspection; one person using the service said, “Things have got better” To promote service users rights to information, current service users had been provided with an up to date, clear, accurate guide to the home, which included all the proper details. Individual care plans had improved; they had more detail and instructions for staff to follow. People using the service had been involved with their care plans one said, “I read through my care plan, before signing it” Improvements had been made with medication practises and records, to help make sure people get their medication safely and at the right time. Things had improved in the standard of the accommodation; parts of the home had been upgraded and redecorated, to provide people living there with a better standard of accommodation To make sure managers and staff do the right thing to make sure people are properly protected, the instructions for dealing allegations, incidents and suspicions of abuse had been changed. The procedure for making complaints had been made clearer, so that people know how to raise concerns and what should happen if they do. To show staff were being properly recruited and checked out before starting work at the home, good recruitment records were available. A manager had applied to be registered with the Commission, to take legal responsibility for the day-to-day running of the home. Records were being kept available to show things in Healy House were being serviced and checked for the safety of people living in the home. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Healy House (Burnley) DS0000009528.V360699.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 Healy House (Burnley) DS0000009528.V360699.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. 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. This service must show continual good practice; in ensuring peoples needs and abilities are properly considered and planned for, before they move into the home. EVIDENCE: The Statement of Purpose and Service User Guide had been revised and updated by the Registered Provider to include the require information; copies had been previously made available to the Commission. Copies of these documents were seen to be available in the homes office. The acting manager said each person living in the home had been given a copy of the updated service guide; records had been kept in support of this. Two people using the service indicated they had seen the guide. There had not been any new people admitted to Healy House since the last inspection. Therefore the assessment and admission procedures and practices were unable to be fully assessed at this inspection visit. However, the acting manager said she would be a key part of the assessment of any new people. She explained this would involve the completion of an assessment tool, with Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 10 the gathering of information from relevant sources, such as the person themselves, Social Services and Health professionals. The assessment and admission process was discussed further with acting manager and advice was given on ensuring any complex needs are properly considered and planned for. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although progress had been made in planning and responding to peoples’ individual needs and choices, the service must continue to develop in providing appropriate person centred care and support. EVIDENCE: People spoken with, were aware of their individual plans and what was written in them. Progress was being made with ensuring people using the service, have their needs identified and responded to in an individual plan of care. The acting manager explained that each person’s plan had been reviewed and updated with their involvement. A new care plan format was being introduced which set out identified needs, goals and actions to be taken by staff to respond to and meet people’s needs. The care plans seen, described potential goals and the action to be taken in response. Short term goals had been Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 12 recorded separately, for easier staff reference. A system had been introduced to highlight and monitor any changes in peoples’ behaviour. This had helped in ensuring a more consistent approach to providing support for people using the service. Some significant information in relation to peoples mental ill health had not been properly included in care plans seen, the acting manager agreed to take action to ensure these needs are identified and responded to in individual care plans. Observations of support practices and information care plans, showed people were being supported to make some choices and decisions in their daily lives. Some care plans included separate agreements in relation to alcohol, smoking community access and financial matters; however, these agreements were not always being adhered to. Staff were not always sure how to respond when people did not abide by their care plan agreements, which meant boundaries were unclear or inconsistent. Other relevant agencies had been made aware about these situations. Progress had been made in reviewing and completing peoples’ individual risk assessments to help ensure people are supported as safely as possible, and risk management strategies were being completed in response to behavioural needs. Risk assessments were seen in relation to two people, they identified the specific risks which had been graded between ‘low’ and ‘high’ level risks. Instructions had been defined explaining how the risks were to be minimized. There were some conflicting practice issues between supporting individual risk taking and the services’ duty of care. The importance of ensuring risk assessments are completed, reviewed and updated, in response to changes in peoples needs, behaviours and circumstances was discussed with the acting manager. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People had opportunity to take part in community activities, but this did not always result in a positive or safe experience. EVIDENCE: People living at Healy House spoke of the various activities, both in and out of the home they were involved with, including ‘voluntary work’, pubs, Churches, sports/fitness centres, shopping, games, DVDs library and cinema. Promoting individual rights and choices was apparent in support practice, but this did not always fully consider the protection of individuals, or the benefits of some of the activities being condoned. This meant, outcomes for people had not always been positive. Records and discussion did show the acting manager had recognised difficulties in maintaining a balance between personal safety; rights Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 14 and choices, therefore other relevant agencies had been contacted for support and advice. A senior support worker had been given the role of activities coordinator. A resource file was being set up of suitable educational and fun/leisure activities. General and individual risk assessments were in the process of being devised, on people accessing the various resources. A budget had been made available for activities. People spoken with said they were keeping in touch with families and friends, by telephone and visits. House meetings were being held weekly to discuss meals, menus, activities and outings. “We voice our opinions, the opportunities there to do it,” explained one person. Independence living skills were being encouraged, people were responsible for tidying their rooms, they made drinks and snacks for themselves and said they were involved with shopping and cooking. Those spoken with said they were happy with the food available and confirmed that menus were being agreed each week. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Most procedures and practices were satisfactory in monitoring and responding to peoples’ health care needs. EVIDENCE: It was apparent from discussion and observation; people were generally being supported to take an interest in their appearance, hairdressing and clothing. Some prompting of personal hygiene practices had been included as appropriate, in care plans. Routines of daily life were flexible; including what time people got up and went to bed. Some of these daily routines had been agreed and responded to in individual care/support plans, to promote more constructive and focused lifestyles. Care plans also included a ‘health check’ assessment and the acting manager said annual appointments were being made for people receive a health check with their GP. Records showed people were being supported to keep hospital, and other health appointments. Mental health care needs needed to be better identified and responded to within individual care plans. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 16 A system had been introduced for the auditing of medication practices had been introduced. Storage facilities were satisfactory; temperatures were being monitored. Medication records seen were generally clear and accurate. It was evident verification on any medication changes were being obtained for GPs. Assessments had been carried as appropriate on peoples ability to manage their own medication, consent forms were seen agreeing to any staff support. Individual protocols had been defined on giving ‘when required’ medication, it was recommended these be more explicit to provide clearer guidance for staff. The acting manager said the GP had been contacted to ensure clearer instructions are specified on topical items. Most staff had received medication management training or this was being arranged. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Not all procedures and practices were effective in promoting the protection of the people using the service. EVIDENCE: One person using the service said, he was aware of the complaints procedure and that he felt the house meetings were useful in voicing opinions and “getting things sorted out” A summary of the procedure had been displayed in each bedroom, this provided assurances about making complaints. A more detailed procedure with timescale and contact details, was included in the service user guide, each resident had been given a copy of the guide. The acting manager said there had not been any recent complaints from residents, but that systems were in place to ensure any complaint is properly dealt with. Protection and abuse safeguarding policies were seen to be available, they had been updated to include more appropriate guidance and instructions for staff. One staff member spoken with expressed an understanding of how to respond to allegations, incidents and suspicions of abuse. The acting manager and 3 staff had received POVA (Protection Of Vulnerable Adults) training this was being arranged for newer staff. Some staff had received ‘conflict resolution’ training and further training had been arranged. As indicated previously within this report, some support practices at Healy House did not always provide effective safeguards for people using the service. The acting manager had Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 18 contacted relevant agencies in relation to specific issues, however, it was strongly advised further contact be made. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Progress had been made in providing a pleasant and homely environment; this must be sustained for the benefit and well being of the people using the service. EVIDENCE: This inspection showed the home had a satisfactory standard of facilities and accommodation, progress being made in a number of areas. The lounge provided a comfortable and pleasant room for the residents. Work had been carried out to up-grade the shared bedroom, new curtains and a table and chairs had been provided, this improvement was very much appreciated by one person spoken with. A new dining table and chairs had been provided in the kitchen. Work was ongoing to upgrade the ground floor bedroom. Records showed repairs to the home were being identified and responded to. Plans were being made to upgrade the kitchen. The home was found to be generally clean; the laundry facilities remained satisfactory. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34, and 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. For the benefit of the people using the service, Healy House must show continued good practice in relation to staff recruitment, staffing levels, training and development. EVIDENCE: There had again been some changes in staff in the staff team, one person spoken with said “we get used to them changing” Generally, positive comments were made about the current staff, one person said “they are a good team at the moment”. The staff rota showed satisfactory staffing levels were in place and sufficient numbers of staff were on duty on the day the home was visited. Senior staff had been recruited to provide leadership in the absence of the manger. Staff spoken with, generally considered staffing levels to be adequate in providing support for the people using the service. There was some indication that staff had been asked to cover shifts in other homes, also that arrangements for providing appropriate support for individuals, may not always be effective. However, the acting manager said that extra staff could be on duty if needed and risk assessments had been carried out specific Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 21 individual support. Staffing arrangements and staff turnover was discussed with the acting manager, in terms of promoting sustained continuity of support for the wellbeing and safety of people using the service. Two new support workers had been recruited to work at Healy House; recruitment records were readily available in the home. Records showed show that satisfactory checks had been carried out, for the protection of the people using the service. People using the service had been involved in selecting staff to work in their home. The induction training records of the new employees were seen; a new more wide-ranging programme had been introduced. One member of staff spoken with confirmed training was ongoing. It was suggested the induction training record indicate the arrangements made for the supervising of new staff. Records and discussion showed progress had been made in ensuring staff receive appropriate training, including NVQs (National Vocational qualifications) Basic courses such as first aid, fire safety, infection control and also more specialised training in ‘approaches to mental health’, ‘schizophrenia’ and ‘epilepsy’. Staff spoken with, confirmed staff meetings were being held and they had opportunity to meet with the acting manager for one to one supervision. It was advised the format for the supervision session, routinely recognise and acknowledge good practice. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Healy House must ensure continued effective leadership and good management practices, for the benefit and well being of the people using the service. EVIDENCE: The Commission for Social Care Inspection has ongoing concerns about the operation and management of Healy House. There has been evidence of historical erratic performance at the home, which has lead to a lack of sustained good practice over time. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 23 This key inspection showed progress in the general management of the home, including meeting previously made requirements. However, there had again been some changes in management staff at Healy House. The need to ensure a consistent management approach in particular, in relation to care plans, risk assessments, staff development and continuity; was discussed with the acting manager. The acting manager had recently been applied for registration with the Commission. Both people using the service and staff made positive comments about the conduct and ability of the acting manager. Quality assurance processes were discussed with the acting manager. An AQAA (Annual Quality Assurance Assessment) had previously been completed. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also provides some numerical information about the service. Effectively completing the AQAA was discussed with the acting manager. In particular, ensuring sufficient details are noted and utilising the process for ongoing quality assurance. The acting manager explained she quality surveys were discussed with people in the last house meeting, also, that surveys had been sent out to relevant professionals. Documentation was available to show that installations and equipment, such as electrical wiring and appliances had been serviced. Arrangements had been made for the gas appliances to be serviced. Records showed fire drills and fire equipment tests were being carried out. Fire risk assessments were also available in the home. General health and safety risk assessments had been carried out. The training matrix and discussion showed progress had been made in ensuring all staff receive training in safe working practices. The acting manager was aware this training needed to continue and be updated accordingly. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 X X 3 X Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard YA2 Good Practice Recommendations To make sure the service can effectively meet the needs of people using the service, admission procedures and practices should ensure a full needs and abilities assessment is carried out and appropriate arrangements made to meet and plan for peoples identified needs. To make sure people receive proper care and support, service users plans should provide clearer details and instructions for staff, in relation to any diagnosed mental illness. To ensure people using the service are supported in consistent manner, action should be taken to ensure specific agreements in care plans are more effectively managed. To ensure a reasonable balance is achieved between personal safety acceptable risk, action should be taken to ensure risk assessments are completed, reviewed and updated, in response to changes in peoples needs, behaviours and circumstances. With appropriate strategies DS0000009528.V360699.R01.S.doc Version 5.2 Page 26 2. YA6 3. YA7 4. YA9 Healy House (Burnley) 5. 6. YA12 YA24 7. 8. YA32 YA37 being put in place to minimize identified risks. Action should be taken to ensure community links and social inclusion activities encourage more positive outcomes for people using the service. To ensure people using the service live in a safe, comfortable and pleasant environment, action should be taken to ensure the home continues to be promptly maintained and upgraded. To ensure people using the service are effectively, consistently and safely supported, staffing arrangements should continue to be appropriately managed. To ensure people using the service benefit from living in a well run home, management practices and leadership, must continue to be efficient and effective. Healy House (Burnley) DS0000009528.V360699.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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