Inspection on 16/05/06 for Healy House (Burnley)

This inspection was carried out on 16th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 25 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Healy House (Burnley) 12/03/08

Healy House (Burnley) 02/08/07

Healy House (Burnley) 14/12/06

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 16th May 2006 10:00 Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 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.V289660.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2005 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 dinning 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 £450 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.V289660.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took 14 hours and was carried out over two days by one inspector. Feedback was given on additional visit, most timescales for action in making improvements, were agreed with Mary Healy, registered provider. 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 registered provider and staff were spoken with. A tour of the premises was carried out. Some policies and procedures were looked at. Areas that needed to improve from the previous inspection were looked at for progress made. The home was assessed against the National Minimum Standards for Younger Adults. What the service does well: Relationships between the service users and staff were good, people living at Healy House were being involved with some day-to-day matters. House meetings were being held each week, so people could voice their opinions and be asked about things which affected them, such as meals and group activities. Everyone was being given opportunity to get out into the local community and join in different activities. “Oh yes, we get out and about” Service users said they enjoyed playing pool in the next door property. Contact with relatives and friends was good, people said they were keeping in touch with their families. Everyone was happy with the meals provided, people were involved with choosing menus and cooking. Healthy eating was being encouraged. “ We’re having a three course meal tonight” commented one person. “ The food is really good, I help cook on Thursdays, we get a choice” said another. People were being given support with healthcare, keeping hospital appointments and seeing their GP. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: This inspection showed little progress had been made in improving the service at the home. There were 11 outstanding requirements from previous inspections and 13 additional requirements. The homeowner therefore needed to take urgent 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; a temporary manager should be in post to oversee the running of the home. More staff were required to work at the home, to make sure there are enough to provide support flexibly. The home needed a lot of improvements inside and outside, to provide people living there with a good standard of accommodation, including decorating and upgrading. There were health and safety matters needing urgent attention, and basic privacy needs had been ignored. There was only one toilet, another must be provided, so there enough for people living in the home, staff and visitors. The shower and bath still needed thermostats to provide safe water temperatures. To reduce the spread of germs the laundry walls and floor must be none absorbent and easy to clean. To make sure people’s medication is managed as safely as possible, dosage instructions must be followed, staff needed further training and medication guidelines needed updating to provide clear up to date instructions. Guidelines for protecting people from abuse were still in need of changing, to make sure managers and staff do the right things. Some bedrooms needed more things, unless people agreed they didn’t want or need them. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 7 Information about people living in the home and Plans showing staff how to provide support to individuals needed improvement; to make sure people are properly treated. To protect people, proper checks needed to be carried out before letting staff start work in the home. Staff training needed to continue in first aid, health and safety, food hygiene, mental ill health and NVQ training (National Vocational Qualifications) The guide to the home needed to be improved, so people are clear about the services and accommodation is available. Staff should be linked with individual service users to oversee their support, build sound relationships and clarify responsibilities. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@The Commission for Social Care Inspection .gsi.gov.uk or by contacting your local CSCI office. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 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.V289660.R01.S.doc Version 5.1 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): 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. The lack of assessment details suggested peoples’ needs may not have been fully considered, and staff were not fully aware of these needs. EVIDENCE: The guide to the home was seen; this had not been finished off properly and was out of date due to changes in the home. Service users spoken with said they had not been given a copy of the guide. The last inspection report from the Commission was not readily available in the home. The service users initial assessment details were still not available in the home. A service user had recently moved into Healy House from another home in the company, without a proper reassessment of needs, another service user was visiting the home for a trial period, there was no assessment information about needs, abilities or diagnosis available in the home. Staff spoken with said they had not seen any assessments, but they had been told verbally about people’s basic support needs. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 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 adequate. This judgement has been made using available evidence including a visit to this service. The service users changing needs and personal goals were not all properly noted in Individual Plans, resulting in a lack of planning of agreed support. The service users had involvement with the daily running of their home. Risk taking had not been properly assessed and planned for, which could affect the service users ’ wellbeing and safety. EVIDENCE: Two of the service users did not have Individual Plans, or goals and needs identified and agreed. The Individual Plans seen as part of case tracking did include agreed longer term goals and support needs, but did not include enough details of the steps needed to reach goals. Staff spoken with said they were “just getting to know the new service users” Mary Healy said the Individual Plans were to be reviewed. 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 Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 11 had been raised and discussed, including holidays and outings. The records did not include any action plan or show who was to follow up matters raised, it was suggested this matter be improved. Service users were seen to take risks in their daily lives, but there had been a change in the format for assessing and managing risks, strategies did not provide clear instructions for staff on how to respond and some risks had not been properly considered. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 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): 12,13,14,15,16,17 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. Individual Plans showed planned activities and outings. 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. Two service users said they had enjoyed a holiday abroad and were hoping to go again. One service users had been tending the garden areas. Service users were seen playing pool on both days 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. Independence living skills were being encouraged, service users kept their Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 13 rooms tidy and did their own laundry, they had freedom of movement in the home. Individual Plans needed to show service users agreement with chores. 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 some of the meals being served. The weeks menu was being discussed in house meetings; a three course meal had been introduced one day per week. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 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 poor. This judgement has been made using available evidence including a visit to this service. People’s health and general wellbeing was being monitored, support being provided to access health care services. Support with personal matters needed to be dealt with more sensitively, to promote the service users’ dignity, privacy and sense of value. Medication management needed improvement for the protection of the residents. EVIDENCE: Arrangements had not been made to enable one service user to celebrate a birthday; this had been forgotten, therefore the birthday had to be celebrated a day later. One service user was being accommodated in a bedroom without any curtains; this matter was dealt with at the time of the visit. There was no mirror in the en-suite bathroom, which meant having to use the house bathroom for shaving. Records showed service users were registered with a General Practitioner and that appointments had been made and kept, appointments had also been kept with care coordinators, consultants and community psychiatric services. Daily records included reference when necessary, to each resident’s condition. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 15 Records showed there had been several incidents in the home involving service users but the Commission had not been notified of these. The medication policies and procedures were available, but still had not been revised to provide more up to date guidance. None of the staff responsible for medication management had received accredited training. The dosage instruction one item of medication stated ‘one twice per day’, but on one occasion it had been given three times in one day. Mary Healy registered provider said this was in response to hospital instruction, but there was no written evidence to support this. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 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 adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure provided guidance on raising complaints. No progress had been made in updating the protection and abuse policies and procedures; this may result in abuse matters not being properly dealt with. EVIDENCE: The complaints procedure was in the service user guide; this had been updated included the contact details of the Commission. Systems were in place to record and follow up complaints. Service users had an awareness of the procedure but said most issues were raised and discussed, in the weekly house meetings. Staff spoken with expressed a basic understanding of how to deal with complaints. The protection/abuse policies and referral procedures had not been revised and updated, they included inappropriate details about consent issues. The staff whistle blowing policy had not been updated. Staff spoken with had a basic awareness of protection issues. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 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 poor. This judgement has been made using available evidence including a visit to this service. Limited progress had been made in improving the standard of décor and furnishings, with no evidence of future planning. Therefore the home did not provide a safe, pleasant and homely environment for the service users. EVIDENCE: A new leather sofa and chairs had been provided in the lounge, a wash hand basin had been fitted in the laundry. New patio furniture had been provided. One bedroom had an en-suite shower and toilet (the shower was not yet in working and there was no supporting paperwork to show this facility was in order) The outward appearance of the home was poor; the windows of the home were in a poor state and the property looked unkempt and uninviting. The ceiling and walls were still covered in ‘office style’ panels; there was fluorescent strip lighting. The carpets in communal areas looked shabby. There was no toilet on the ground floor. There was no evidence to indicate plans were being made to up-grade the home. The home was generally clean. The carpet tiles in the bathroom were discoloured, the registered provider said these were to be replaced. The laundry walls and floor were not easily cleanable. The record of water temperatures showed some irregularities and it was not clear if the shower had been fitted with a suitable thermostat. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 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 not entirely satisfactory in providing service users with effective and consistent support. Recruitment practices showed full attention was not being given to protecting the service users. EVIDENCE: There had again been some changes in staff. Staff on duty were new or inexperienced, but they interacted well with the service users, and appeared well motivated and enthusiastic. Service users made positive comments about the staff team. Staff rotas and records of hours worked, showed staffing levels were not always sufficient in providing appropriate support, for example staff absences were not always being covered and there was regularly only one person on duty from 5 pm. Staff were providing waking watch night cover. Service users had been involved with staff recruitment; this was being encouraged. Staff records had some required details missing for example; one had only one written reference, two did not include declarations about previous convictions, dates of education/further education had not been requested, comments in one reference had not been followed up and references had been obtained from relatives. Medical declarations did not include sufficient information to make an Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 19 informed judgement about health matters; in particular details about mental health issues had not been requested. Records were seen of structured induction training for the new staff, but initial basic instruction was not being given. NVQ training and training in safe working practices was ongoing however, there were no up to date records to support this. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 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 running of the home for the benefit of the service users. EVIDENCE: A completed application for registered manager had not been received at the Commission. Mary Healy, registered provider was managing the home, the house manager who was new to the home and not in post at the last inspection visit had left. Mary Healy had other commitments within the company which needed her attention; this had affected the smooth running of the home. Some work had been carried out in reviewing the quality of the environment, but there had not been any recent surveys with service users and others about the support and services provided at Healy House. There was no annual development plan available. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 21 The fire records showed drills and tests had been carried out; additional fire safety equipment had been fitted. There were health and safety matters in need of attention, the plug on the television was broken and the electrical socket was cracked, staff had initially reported this matter on 17 April, this matter was dealt with at the time of the visit. The carpet in the ground floor bedroom had rippled and presented as a tripping hazard. It was not clear if the disused wall lights in the lounge were still connected to the electrical supply. Documentation was not readily available to show that installations and equipment had been serviced. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 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 2 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 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 2 2 X 1 X 2 X X 2 X Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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 (Timescale of 08/07/05 not fully met) Copies of the most recent Inspection Report must be readily available in the home. Records of service users initial assessment must be kept available in the home. (Timescale of 03/02/05 not met) New service users must not be admitted to the home, without a needs assessment/review by the relevant Care Coordinator/Social Worker. Each service users must have a written individual Plan outlining their needs and abilities and personal goals. Risk assessments/management strategies must be completed on service users engaging in activities, which may affect their DS0000009528.V289660.R01.S.doc Timescale for action 30/06/06 2. 3. YA1 YA2 4,5,6 14,17 30/06/06 30/06/06 4. YA2 14,17 30/06/06 5. YA6 15 30/06/06 6. YA9 13 30/06/06 Healy House (Burnley) Version 5.1 Page 24 health or well-being. 7. YA18 12 Service users privacy needs must continue to be respected. Suitable curtains or blinds must be fitted to the windows of bedrooms. Any incident which affects the well being of a service, user must be notified to the Commission without delay. All staff responsible for dealing with medication must receive accredited medicines management training (Timescale of 31/03/06 not met) Medication management policies and procedures must be in accordance with current recognised guidelines and legislation (Timescale of 31/03/06 not met) Service users must only be given medication as per the prescribed dosage instructions as specified upon the label. The protection and abuse policies and procedures must be amended to include appropriate details for responding to suspicion, allegation or evidence of abuse or neglect (Timescale of 31/03/06 not met) The windows of the home must be repaired/replaced. The home must be refurbished to a satisfactory standard. (Timescale of 30/04/06 not met) Documentation must be made available to show the new ensuite facility meets the requirements of the various authorities and agencies. A toilet must be provided on the ground floor (Timescale of DS0000009528.V289660.R01.S.doc 30/06/06 8. YA19 37 30/06/06 9. YA20 13,18 18/08/06 10. YA20 13 30/06/06 11. YA20 13,18 30/06/06 12. YA23 13 30/06/06 13. 14. YA24 YA24 16,23 16,23 30/06/06 29/09/06 15. YA24 16,23 30/06/06 16. YA27 23 29/09/06 Healy House (Burnley) Version 5.1 Page 25 30/04/06 not met) 17. YA30 16,23 The laundry floor must be made impermeable, the walls washable (Timescale of 30/04/06 not met) Sufficient numbers of staff who are trained and competent to meet the needs of the service users, must be available to work in the home at all times. The recruitment process must include the obtaining of full and satisfactory written references and the recording of information to show all appropriate checks have been carried out. (Timescale of 30/11/05 not met) Staff induction must include initial orientation training about key responsibilities of the role. There must be a structured training and development programme, which ensures all staff receive training in response to their identified needs and the requirements of the Care Home Regulations. A suitable manager must apply for registration with the Commission (Timescale of 10/02/06 not met) A formal system for reviewing and improving the quality of care with the involvemnt of service users and others, must be implemented. A suitable thermostat which provides water at a safe temperature must be fitted to the bath and shower (Timescale of 03/02/06 not met) Action must be taken to assess the home for risks to service DS0000009528.V289660.R01.S.doc 29/09/06 18. YA33 18 31/07/06 19. YA34 17,19 30/06/06 20. 21. YA35 YA35 18 18 30/06/06 30/06/06 22. YA37 8 31/07/06 23. YA39 24 31/07/06 24. YA42 13 30/06/06 25. YA42 13 30/06/06 Page 26 Healy House (Burnley) Version 5.1 users and any identified risks must be minimized or eliminated. Arrangements must be made to ensure defective and unsafe equipment; fixtures and fittings are repaired or replaced in a timely way. 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 YA16 Good Practice Recommendations Service user Plans need to include details of the steps to be taken to meet identified goals. Service user Plans should include clear agreement to undertake household chores. The house rules should be reviewed and redefined with the involvement of service users. Every effort should be made to ensure service users birthdays are remembered and celebrated, in response to individual choice. It would be good practice to introduce a ‘keyworker’ system or similar, to help ensure more personal/individual staff support. Suitable storage facilities should be available should a service users be prescribed controlled drugs. The complaints procedure should be discussed with service users periodically. It is recommended managers and staff receive suitable training in receiving and investigating complaints. The outward appearance of the home should be improved. The ceiling in the lounge should be finished off a soon as possible. 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. DS0000009528.V289660.R01.S.doc Version 5.1 Page 27 3. YA18 4. 5. YA20 YA22 5. 6. 7. YA24 YA24 YA26 Healy House (Burnley) 8. YA34 9. 10. 11. YA35 YA37 YA39 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. A suitable acting manager should be employed to provide temporary management cover in the home. The quality assurance system needs to ensure all relevant people are consulted and that a development/action plan is produced. Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Healy House (Burnley) DS0000009528.V289660.R01.S.doc Version 5.1 Page 29 - 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!