CARE HOME ADULTS 18-65
Healy House (Burnley) 11 Ormerod Road Burnley Lancashire BB11 2RU Lead Inspector
Mr Jeff Pearson Unannounced Inspection 14th December 2006 09:30 Healy House (Burnley) DS0000009528.V317646.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.V317646.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.V317646.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 Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16th May 2006 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. There is a dining kitchen with separate dining area and a lounge. There is one shared and three single bedrooms. 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 £380 and £875 per week, there were voluntary optional charges for entertainment and transport. Information about the services provided is usually available in the home. Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Healy House on the 14th December 2006. The visit took 7 hours and was carried out over one day by two inspectors. Areas that needed to improve from the previous inspection were looked at for any progress made. Since the last inspection the registered provider had sent an Improvement Plan and letters indicating that corrective action had been taken, this information was taken into consideration. The registered provider did not complete or return the pre inspection questionnaire to the Commission; therefore the details requested were unable to be fully considered. There were 4 service users accommodated. The files/records of 3 service users were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of residents. The records of the most recently recruited staff were looked at. During the inspection visit, service users, the acting manager, registered provider and staff were spoken with. A tour of the premises was carried out. Some policies and procedures were looked at. What the service does well:
Relationships between the service users and staff seemed good. “I’m quite happy with the home,” explained one service user; “ the staff are decent,” said another. People living at Healy House were being involved with some day-today matters. House meetings were still being held each week, so people could voice their opinions and be asked about things which affected them, such as meals, group activities and outings. People were being given opportunity to get out into the local community and join in different activities. One service user spoke of a recent visit to the shops, park and cinema, another said “I’m planning on going to the gym this afternoon” Contact with relatives and friends was good, people said they were keeping in touch with their families, when asked about this, one service user replied “I’m seeing my dad this weekend, we speak a lot on the phone” Everyone was happy with the meals provided, people were involved with choosing menus and cooking. The service users made the following comments about food, “yes the food is usually good” “they give me some money and I buy any ingredients I need and cook my own meal” “we have some good meals, I help with cooking, I like baking”
Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 6 People were being given support with healthcare, keeping hospital appointments and seeing their GP. What has improved since the last inspection? What they could do better:
This inspection showed some progress had been made in improving the service at the home. But, there were 12 outstanding requirements from previous inspections and 5 additional requirements. Legal Notices issued to the homeowner to make improvements, had not all been fully complied with. The homeowner therefore again needed to take action to improve matters at Healy House, for the benefit of service users and staff. A manager must register with the Commission, to take legal responsibility for the day-to-day running of the home. Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 7 To promote service users rights to information, potential and current service users must each be provided with an up to date, clear, accurate guide to the home, which includes all the proper details. Risks to individuals were not being properly assessed and staff had not been given clear instruction should respond to these situations. To show service users have been properly assessed and that they are suitable for the home, also to make sure staff are aware of their needs and abilities, their assessment information must be available in the home. Service users’ Individual Plans must be readily available to them and staff, reviews must be carried out and Plans updated, to make sure everyone is properly supported. Individual risk taking was not being properly assessed and staff were not being given clear instructions on how to reduce or manage any risks. To protect the service users and staff, proper and clear records must be kept of medication, including when they are given out or changed. To protect service users, proper checks still needed to be carried out before letting staff start work in the home, details of the checks needed to be kept to show they have been properly carried out. To promote the service users rights to complain and have their concerns properly dealt with; each person must be given a copy of the complaints procedure. Staff induction training needed to be provided all new staff, along with training on health and safety, food hygiene. Even though some things had improved, the home still needed attention inside and outside, to provide people living there with a satisfactory standard of accommodation. People living in Healy House, their relatives and others still must be formally asked if things are okay, to make sure the home is being run in their best interests, the home owner must show plans are in place to make improvements. 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.V317646.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.V317646.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 poor This judgement has been made using available evidence including a visit to this service. Service users did not have up to date and accurate details about the home, therefore their rights to helpful, informative written material was limited. It was not evident that all service users’ needs were properly assessed prior to admission. EVIDENCE: The last inspection report from the Commission was readily available in the home. The guide to the home was seen; this was a ‘master’ copy and had not been finished off properly, it was out of date due to changes of managers in the home. It did not include a copy of a contract/statement of terms and conditions, details of fees or service users’ views of the home, there was no reference made to accessing Inspection Reports. Service users spoken with said they were aware of the guide, but had not been given an individual copy. The acting manager said the guide had been updated but not distributed to the service users. A copy of the guide had not been forwarded to the Commission. Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 10 The individual files examined included some initial Social Services assessments, also reviews and care plans drawn up with the involvement of relevant professionals. However, a service user who had been visiting the home for a trial period still had no assessment information about needs, abilities or diagnosis available, despite having been accommodated in the home on several occasions. Also, another file seen did not have any assessment details. Healy House (Burnley) DS0000009528.V317646.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): 6,7,9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service users Individual Plans were not up to date, so changing needs and personal goals were not all properly noted, resulting in a lack of planning of agreed support. The service users were encouraged to make choices and decisions; this meant that they had some control over how they were supported and how they lived their lives. Not all potential risks were identified and staff did not have enough directions on how to manage these. EVIDENCE: Service users spoken with expressed some awareness of their Individual Plans. The Individual Plans seen as part of case tracking included agreed long term goals and support needs, but they had not been updated since they were
Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 12 written in October 2005. One care plan was could not be located. The acting manager said some reviews had taken place, but was unable to provide any written evidence to support this claim. Service users were seen to be involved and consulted about day-to-day matters, such as meals mealtimes and going out. Service users said ‘house meetings’ were being held each week, records seen showed various matters had been raised and discussed, including menus activities and feedback on new staff. There was a risk assessment in the residents’ files but this did not cover all risks. For example, some residents were observed to go into the community independently. This was not properly risk assessed. The risk assessment did not indicate what the level of risk was, whether it was a high, medium, or low risk, and did not properly inform staff on how to minimise or manage any risks. Healy House (Burnley) DS0000009528.V317646.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): 12,13,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users had a degree of independence, they had opportunity to take part in chosen activities, access community resources and keep in touch with families and friends. The meals were sufficient in providing for the service users tastes, choices and diet. EVIDENCE: During the inspection service users went out into the local community. Service users spoke of the various activities, both in and out of the home, including Greenspace, day centres, pubs, shops, church, sports/fitness centres, shopping, games and cooking. Service users were seen playing pool on the day of the inspection. Service users spoken with explained they were keeping in touch with members of their families and friends, by telephone, visits, or short breaks away.
Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 14 Independence living skills were being encouraged, service users kept their rooms tidy and some did their own laundry, they had freedom of movement in the home. Mealtimes were flexible, depending what was happening in the home. Service users made drinks and snacks for themselves and said they could get involved with shopping and cooking. Healthy eating was being encouraged; fresh fruit was available. Records showed the meals being served, but needed to include details of vegetables. The weeks’ menu was being discussed in house meetings and was displayed in the home’s kitchen. Healy House (Burnley) DS0000009528.V317646.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): 18,19,20 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The lack of health monitoring meant service users’ health care needs were not fully met. Medication management practices did not fully protect the service users and staff. EVIDENCE: The service users said they did not need much support with personal care. Some prompting of personal hygiene practices had been included in Individual Plans. It was apparent from observation; people were being supported to take an interest in their appearance, hairdressing and clothing. Routines of daily life were flexible and residents were able to make decisions about their lives, including what time they got up and went to bed, and when they had some meals.
Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 16 The acting manager said that a health check assessment was to be introduced for each person, but there was no evidence to show these had been completed. Records showed contact with health care professionals such as GPs and CPNs (Community Psychiatric Nurses) Support was being given to attend hospital appointments. The lack of up to date Individual Plans; raised questions about ensuring an appropriate response to health care needs. Records seen showed some peoples’ weight had previously been consistently monitored, but the records had not been completed for over a year, it was suggested weight monitoring be carried out in response to individual needs and circumstances. Medication storage facilities were satisfactory. Staff who had responsibility for administering medications were undertaking medication training, but this had not yet been completed. Detailed individual assessments had been completed with residents on their ability to manage their medication and signed consent forms were seen agreeing to staff support. The medication management policies and procedures had been revised and updated to include current good practice, it was noted the procedures did not provide clear instructions for staff on managing ‘when required’ medication. There were some gaps on the medication administration records with no explanation given. One service users’ medication instructions had been changed, but not confirmed by someone else as correct. The changes had not been properly recorded on the medication record sheet, which made the instructions appear unclear. There were no individual protocols on giving ‘when required’ medication. Instructions for applying medicated cream did not specify ‘where’ it was to be applied. Healy House (Burnley) DS0000009528.V317646.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): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems and procedures for managing complaints were unclear and did not show service users’ rights were being effectively promoted. The safeguarding adults policies and procedures promoted the protection of the service users. EVIDENCE: The complaints procedure was in the service user guide; but this had not been distributed to service users. Service users spoken with had some recollection of the complaints procedure, but did not have a clear understanding of the referral procedures. They said they had not been given a copy of the procedure. Although the acting manager was aware of a complaints recording system he was unable to locate this information. The safeguarding adults policies and referral procedures had been revised and updated, they included guidelines on recognising abuse and the action to be taken by staff. The inappropriate statement about consent matters had been amended. Records showed staff had been requested to read, and sign in confirmation of their understanding of the revised procedures. Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 18 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): 24,30 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home did not provide a pleasant and homely environment for all service users. EVIDENCE: The home was found to be generally clean; records showed cleaning schedules were being kept up. The laundry floor had been covered in asphalt and the walls had been plastered but were awaiting suitable paint covering. The wall on the staircase had been re-plastered and was awaiting further decoration. Scaffolding was seen at the front and rear of the home, which indicated work was on going, but the new windows had not yet been fitted. The registered provider said work to extend the property had been held up due to planning regulations.
Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 19 One bedroom seen was decorated and furnished to a good standard. The ensuite shower in one room was still not working and there was still no supporting paperwork available to show this facility met with requirements of local authority agencies. Curtains had been fitted but there was no light shade in the bedroom or mirror provided in the en-suite. The shared room was in a poor state the wallpaper was dirty and the curtains were tattered and hanging down, there was no privacy screening. The service users had not been provided with lockable facilities. The ceiling and walls in the lounge were still covered in ‘office style’ panels; there was fluorescent strip lighting. The carpet in the lounge looked shabby. Healy House (Burnley) DS0000009528.V317646.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): 32,34,35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The staffing arrangements were satisfactory in providing service users with appropriate support. Recruitment practices showed full attention was again not being given to protecting the service users. EVIDENCE: There had again been some changes in staff in the staff team, two new staff had been employed and staff from other homes in the organisation were now based at Healy House. The staff rota showed appropriate staffing levels were in place and sufficient staff were on duty on the day the home was visited. Arrangements had been made to provide awake night support staff. The residents spoken with were generally appreciative of the staff team, but commented ‘they are always changing’
Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 21 There was evidence to indicate service users had been involved in recruiting staff. Staff records had some required details missing for example; gaps in employment had not been explored, dates of education had not been requested therefore a full history could not be traced. References obtained in respect of one person, were not from the named referees on the application form and references had been obtained after the employees had commenced work. References had not been sought from an employer where an applicant had previously worked in a care setting. There was no evidence to the show supervision arrangements of new staff awaiting CRB (Criminal Record Bureau) clearance. There was conflicting information about convictions, which had not been explored or clarified. The above findings indicated the homes recruitment and selection policy was not being properly followed. The policy seen was not in line with the Care Home Regulations, in terms of ensuring gaps are explored and suitable references obtained. There were no completed induction training records for one of the new employees. Training records showed one member of staff had completed NVQ (National vocational Qualifications) level 2, another had completed NVQ level 3 and three people were working towards gaining NVQ 2. Healy House (Burnley) DS0000009528.V317646.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): 37,39,42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management arrangements did not provide for effective day-to-day or long term, running of the home for the benefit of the service users. EVIDENCE: Evidence included within this report indicates shortfalls in relation to the management and daily running of the home. There was no registered manager at the home and the Commission had not received an application for this position. The acting manager had been in post for approximately five months, had minimal experience and was being supported by Mary Healy, registered provider and a registered manager from another home in the organization. Records and discussion showed the acting manager was undertaking NVQ level 3 and had completed abuse/protection and food safety management training.
Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 23 Following the findings of the last key inspection, which included a visit to the home on 16/05/06, the Commission issued statutory requirement notices for improvement in seven specific areas. This second key inspection, showed a failure to comply or fully comply, with six of the requirement notices. The home was to be re-assessed for Investors In People accreditation in January 2007. House meetings provided some opportunity for the service users to be consulted and voice their opinions. The acting manager said there had not been any quality surveys for service users and others to find out about the home’s performance. There was no annual development plan available. Previous inspection reports have identified significant matters for improvement; these have not been implemented within agreed timescales. A safety handbook was available for staff, this included health and safety policies and procedures. Records showed a fire drill had recently been carried out. Health and safety risk assessments were in the process of being completed by a contractor. Documentation was not readily available to show that installations and equipment had been serviced. Not all staff had undertaken training in safe working practices, there was no clear evidence to show this had been arranged or planned for. Healy House (Burnley) DS0000009528.V317646.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 1 2 1 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 2 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 1 X 1 X 1 X X 2 X Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 4,5,6 Requirement The statement of purpose and service user guide must include clear factual information about the services and facilities provided. A copy of the revised service user guide must be given to each service user (Timescales of 08/07/05 and 30/06/06 not fully met) A copy of the guide must also be forwarded to the Commission. Records of service users initial assessment must be kept available in the home. (Timescales of 03/02/05 and 30/06/06 not fully met) Service users plans must be readily available, kept under review and revised accordingly with the involvement of the service users. Risk assessments/management strategies must be completed on service users engaging in activities, which may affect their health or well-being. (Timescales of 30/06/06 not met) All staff responsible for dealing with medication must receive accredited medicines management training (Timescales of 31/03/06 and
DS0000009528.V317646.R01.S.doc Timescale for action 14/12/06 2. YA2 14,17 14/12/06 3. YA6 15 02/03/07 4. YA9 13 02/03/07 5. YA20 13,18 14/12/06 Healy House (Burnley) Version 5.2 Page 26 18/08/06 not fully met) 6. YA20 13,18 Accurate records must be kept of all medication transactions, including when they are administered to service users and clarification when they are not. Any changes to medication must be properly agreed and appropriately recorded. Instructions for applying creams must specify where the cream is to be applied. All service users must be provided with a copy of the homes complaints procedure. Records of any complaints made must be available in the home. The home must be refurbished to a satisfactory standard. (Timescales of 30/04/06 and 29/09/06 not met) Documentation must be made available to show the new ensuite facility meets the requirements of the various authorities and agencies. (Timescales of 30/06/06 not met) The windows of the home must be repaired/replaced. (Timescale of 30/06/06 not met) The front shared bedroom must be decorated and refurbished to a satisfactory standard. Privacy Screens must be provided. The laundry walls must be made washable (Timescales of 30/04/06 and 29/09/06 not fully met) The recruitment process must include the obtaining of full and satisfactory written references and the recording of information
DS0000009528.V317646.R01.S.doc 02/03/07 7. YA22 17,22 02/03/07 8. YA24 16,23 14/12/06 9. YA24 16,23 02/03/07 10. YA24 16,23 14/12/06 11. YA24 16,23 31/03/07 12. YA30 16,23 31/03/07 13. YA34 17,19 14/12/07 Healy House (Burnley) Version 5.2 Page 27 14. YA37 8 15. YA35 18 16. YA39 24 17. YA42 13,23 to show all appropriate checks have been carried out. (Timescales of 30/11/05 and 30/06/06 not met) A suitable manager must apply for registration with the Commission (Timescales of 10/02/06 and 31/07/06 not met) Staff induction must be provided which includes initial orientation training about key responsibilities of the role. (Timescales of 30/06/06 not met) A formal system for reviewing and improving the quality of care with the involvement of service users and others must be implemented. (Timescales of 31/07/06 not met) All saff must receive training in safe workin g practices, as specified in standard 42.2 of the National Minimum Standards for Younger Adults. 31/03/07 02/03/07 31/03/07 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA20 Good Practice Recommendations Service user Plans should be reviewed and updated at least six monthly, or more frequently if required. The medication management policies and procedures should provide clear instructions for staff on supporting service users with ‘when required’ medication. Individual protocols should be devised to ensure service users receive appropriate support with ‘when required’ medication. Another member of staff should verify any changes in medication dosage instructions.
DS0000009528.V317646.R01.S.doc Version 5.2 Page 28 Healy House (Burnley) 3. YA26 4. YA34 5. 6. 7. YA35 YA39 YA42 All service users need to be provided with a lockable drawer/cupboard. Service users’ bedrooms should include the minimum furnishings as outlined in standard 26 of The National Minimum Standards for Younger Adults, unless otherwise agreed. A mirror should be provided in the en-suite bathroom and a light shade in the bedroom. Recruitment practices should ensure references are not requested from the applicants’ family members. The medical declaration should be further developed. The staff application form should request dates of education attendance. The programme of staff training and development needs to continue, to ensure staff are able to respond to the service users needs. The quality assurance system needs to ensure all relevant people are consulted and that a development/action plan is produced. Documentation to show the servicing of equipment and appliances should be readily available in the home. Healy House (Burnley) DS0000009528.V317646.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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
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