Inspection on 04/01/07 for Hough Top

This inspection was carried out on 4th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hough Top 31/08/05

Hough Top 26/04/05

Hough Top 11/01/05

Hough Top 13/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Hough Top 7 Hough Top Leeds West Yorkshire LS13 4QW Lead Inspector Dawn Navesey Key Unannounced Inspection 4th January 2007 11:15 Hough Top DS0000001468.V324618.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 Hough Top DS0000001468.V324618.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. Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hough Top Address 7 Hough Top Leeds West Yorkshire LS13 4QW 0113 204 0155 0113 2040155 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) TACT UK Ltd Mrs Joanne Clare Hargreaves Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2005 Brief Description of the Service: The home is located in the residential area of Swinnow in Leeds not far from Pudsey. It is within easy walking distance of a local parade of shops that includes a post office. Service users use these facilities on a regular basis. The home has a car that is well utilised to take service users to appointments and trips out. A regular bus service is available to travel into the city centre or further afield. Personal care is provided for up to four service users who have learning disabilities. All are currently below the age of 65 years. Nursing care is not provided and the home is supported by local health care services. Accommodation is domestic in style. The home is situated in a quiet street in a residential area. The home is located on two floors and service user bedrooms are situated on the ground floor. They are all single rooms, comfortable and well decorated in the personal style of the individual. There are large enclosed gardens to the rear of the house with a small patio area. The current scale of charges at the home is £1323.57 per week. Additional charges are made for hairdressing, activities, toiletries, clothes, holidays, transport and petrol. Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk One inspector between 11-15am and 4-30pm carried out this unannounced inspection. The purpose of this key inspection was to monitor progress in meeting the requirement and recommendations made at the last inspection and to make sure the home was providing a good standard of care for the people living there. The methods used at this inspection included looking at care records, observing working practices and talking to service users and staff. Most of the service users have complex needs including behaviour that challenges other people. Therefore, discussion with them was limited. They were unable to say how they would like to be referred to in the inspection report but staff refer to them as service users; so this will be used throughout the report. Information gained from a pre-inspection questionnaire and the home’s service history records were also used. There were no visitors to the home on the day of the visit. Surveys and comment cards were sent to service users, their relatives and a number of visiting professionals to the home, asking for their views about the home. Nine of these have been returned. This information has also been used in the preparation of this report. Feedback was given to the senior support worker at the end of the day. Requirements and recommendations made during this visit can be found at the end of the report. Thank you to everyone for the pre-inspection information and for the hospitality and assistance on the day of the visit. Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A service users’ care plan regarding the risk of choking has now got a detailed first aid plan in place. This also includes photographs of how to carry out first aid procedures. A service user who has no relatives has applied to a local advocacy service for an advocate. Cleanliness in the home now seems more thorough and many areas have been newly decorated. Hough Top DS0000001468.V324618.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. Hough Top DS0000001468.V324618.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 Hough Top DS0000001468.V324618.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, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s Statement of Purpose and Service User Guide give good information about the way of life at the home and the standard of support and facilities it can provide. Service users are assessed to make sure that their needs can be met by the home. Service users do not have updated contracts and therefore are not aware of the additional charges made by the home. EVIDENCE: The Statement of Purpose and Service User Guide have been produced in an easy read format, using large print and photographs. These are both kept on display in the entrance hall of the home where families and visitors can have access to them. Each service user also has their own copy and includes the current charges for the cost of the place at the home. Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 10 Service users have a contract with the organisation. The contracts do not have all costs listed in them. Service users are now contributing to petrol for the home’s vehicle. There was no evidence of any agreement having been made to this arrangement. It is not listed in the contracts. Service users’ needs have been assessed to make sure the home could meet their needs, however this was some time ago as all the service users have lived at the home since 1996. Each service user has a service plan, which is similar to an assessment and gives an overview of their current needs. One service user gave a loud and definite “yes” when asked if he was happy at the home. Another service user gave a positive smile when asked if he liked the home. Hough Top DS0000001468.V324618.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, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments, in the main, provide clear detailed instruction on how service users’ needs are to be met. Service users are involved in the day to day running of the home. EVIDENCE: Service users’ care plans are in the main, detailed and give specific information to staff on care and support needs. One service users’ care plan would benefit from more specific instruction and detail regarding his personal care needs and communication signs used. This would make sure that none of his needs could be overlooked. However, staff have a good knowledge of service users’ needs, they were able to accurately describe the care they give and talk about the detail of how service users like to be supported in their daily routines. Staff Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 12 said they had received training in care planning, risk assessment and person centred planning. All care plans had been regularly evaluated and reviewed, with changes being made as needed. Improvements had been made to a service users’ care plan regarding first aid instruction if he should choke on food. This information was in words and pictures, giving clear instruction and guidance to staff. Formal reviews of service users’ needs had taken place. These involved the service user, their family or friends if they wished, staff and other professionals involved in their lives. Some service users had also taken part in some person centred planning and had some goals to work towards from this. All the care plans were linked to risk assessments. Staff and the manager have a good attitude to risk taking. Service users’ safety and rights are maintained while independence is encouraged. Risk assessments were up to date and reviewed. It would be good practice for service users’ relatives or representatives to sign their care plans and risk assessments. This would show their involvement in drawing them up. A service user who does not have any relatives has now applied for an advocate through a local advocacy service. Staff showed a good awareness of the care plans and risk assessments. One staff member explained how staff became familiar with these during their induction and how helpful she had found them. The manager, deputy or senior support worker completes the care plans with input from staff. All care plans and risk assessments are discussed and agreed with staff at team meetings. This makes sure that everyone is aware of all the service users’ needs. Service users have a regular meeting. Topics at the meeting include any forthcoming events, food choices, likes and dislikes, shopping, activities and holidays. Service users were also offered choices throughout the day; what to do, where to go and what to eat. They were also encouraged to take responsibility such as assisting in the kitchen if they wanted to. Service users have very limited verbal communication. Staff showed a good understanding of the gestures and behaviours of service users and what this means in terms of them communicating their needs. Hough Top DS0000001468.V324618.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): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users lead interesting lives and have the opportunity to be involved in a variety of activities. Service users receive a nutritious diet. EVIDENCE: Service users are involved in various activities each week. This ranges from an activity and leisure service, meals out, shopping, drives out, going to the pub, swimming, going to church, plane watching and walks. Activity also takes place in the house; service users have sensory evenings and get involved in household activity such as cooking. One service user has a pet cat, which he adopted when it came to the house as a stray. Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 14 Service users are encouraged to meet up with friends and to keep in contact with their families. Key workers write to friends and relatives on a monthly basis on behalf of service users, giving them updates and sending pictures of events such as parties and holidays. This is good practice. Staff said that service users are known in the local community and use all local facilities such as shops and pubs. A service user attends a local church, where he is an active member, taking part on a rota system as a steward. The diverse needs of the service users are met and they enjoy the lifestyle they want. One service user regularly goes to city centre nightclubs. Staff work flexibly to make sure this happens. The manager of the home makes sure that all service users have an equal share in activities and brings this up at staff meetings if she thinks this is not happening. Service users have at least one holiday each year. One service user told me of a trip to Euro-Disney. Another service user has his own caravan on a caravan park. He uses this regularly throughout the season. Staff make sure risk assessments are completed before holidays take place and also on arrival at holiday destinations. This is good, safe practice. Staff were seen to support people with courtesy and thought for their dignity. Staff said it was important to make sure service users are as independent as possible. They said they are encouraged to get involved in household tasks and to make drinks and snacks for themselves. There was plenty of social interaction between the staff and service users. The atmosphere was relaxed. Menus appear to be well balanced and nutritious. A good variety of food is available and staff try to make sure there is a good selection of fresh produce. Food choices are made on the day and recorded on a menu. This suits the needs of the service users. A service user who needs a blended diet is presented with meals that look attractive and appetising. Some of the service users get involved in doing the weekly shopping. The lunchtime meal was relaxed and made into a social occasion for service users. A service user who has some behaviours that challenge others at meal times was supported properly. Hough Top DS0000001468.V324618.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 good. This judgement has been made using available evidence including a visit to this service. Service users are supported properly with their personal care needs. Health care support is provided in a way that meets service users’ individual needs. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Staff supported service users with their personal care needs in private and with dignity. Staff had good knowledge of their likes, dislikes and preferences. The care plans had details of any health professionals that service users see. These included, GP, dentist, specialist nurse, psychologist, optician and chiropodist. Records are kept of any health appointments and their outcome. Staff always accompany service users on their appointments. Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 16 Some service users have specialist health needs, for example, epilepsy. The majority of staff have not received any training on epilepsy. Staff said this has been arranged in the past, but cancelled due to sickness. This must be rearranged to make sure the needs of this service user are properly met in the event of him having a seizure. Staff said they would call an ambulance if this happened. The home uses a monitored dosage pre-packed system for medicines. All staff take responsibility for the administration of medication and have been trained to do so. There are good ordering and checking systems in place, with a clear audit trail for any unused medication returned to the pharmacy. The medication administration record (MAR) sheets were checked and showed no errors in administration. Hough Top DS0000001468.V324618.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 good. This judgement has been made using available evidence including a visit to this service. Service users or their representative’s concerns are listened to and acted upon. Service users are protected from abuse by the home’s policies and procedures on adult protection. EVIDENCE: The home has a complaints procedure displayed in the entrance to the home. This has been produced in an easy words and pictorial format to make it more accessible to all. Any complaints the home has received have been dealt with properly. Staff have received training on the protection of vulnerable adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse and the whistle-blowing procedure. The organisation has a detailed policy on the protection of vulnerable adults. The organisation has not yet completed their investigation into a recent possible adult protection issue. A staff member has been suspended while the investigation takes place. Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 18 Good records are kept of service users’ finances and their monies are kept safe. Proper handovers of the monies takes place at each shift change and the manager regularly checks the finance records and receipts. Regular checks are made of service users’ belongings and an inventory is made of all their major items of property and clothing. Hough Top DS0000001468.V324618.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 excellent. This judgement has been made using available evidence including a visit to this service. The environment in the home is homely, clean, safe and hygienic. Good staff practices control the spread of infection. EVIDENCE: A tour of the building was carried out, accompanied by a staff member. The home is spacious and well laid out, providing sufficient room for all service users. Service users’ bedrooms have been decorated and furnished, to a high standard, suiting them as individuals. The styles of the rooms show their interests and personality. The home was clean, fresh smelling and warm throughout. Fixtures and fittings are of good quality and the staff had recently redecorated many areas. Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 20 The home has a large, well-kept garden which service users make good use of. Some upgrading of the garden has recently been done with some charitable funding the home has received. Staff said they intend to continue with this project, involving service users as much as possible. A service user whose needs have changed has been able to move to a ground floor bedroom. The staff bedroom is now on the first floor. Clinical waste is properly managed and staff wear protective clothing when attending to service users’ personal care needs. Staff have received training in infection control and were able to say what infection control measures are in place. Some staff have also completed a detailed distance-learning course in infection control. Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 21 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 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are competent to meet the needs of service users; they are well supported and supervised. Service users are protected by the home’s recruitment procedures, however records are not available unless the manager is on duty. EVIDENCE: There are staff on duty throughout the day and night. There are usually two or three staff on the morning and afternoon shifts. At night there is one waking member of staff and one sleeping in, who can be called upon in emergency. The manager has two shifts per week where she is supernumerary and can attend to her management role. Staff said there was always enough staff on duty. Recruitment records were not available for inspection as only the manager has access to these and she was not on duty. Staff said that recruitment is Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 22 properly managed by the home; interviews are held, references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to make sure staff are eligible for work. Staff’s training was mostly up to date. Good records are kept of staff’s training and when their updates are due. The manager assesses this every month to make sure training doesn’t get missed. Staff spoke highly of their training and the support they get from the manager. The manager is aware of the training updates that are needed and has nominated staff for training courses in the near future. The organisation has just sent out their annual training plan to the home. This is comprehensive and covers all the training needs of the staff. The only training gap was training in epilepsy as mentioned in the health and personal care section of this report. One staff member said her induction had been good and prepared her well for the job. Almost 50 of the staff team have achieved an NVQ (National Vocational Qualification) in level 2 or above. Another two staff are currently working on this qualification. All staff said they felt they had a good team and the manager was very supportive. Staff said they felt communication and teamwork within the home was good. Staff said they receive supervision from the manager every six weeks. Staff also said they are encouraged to get involved in special projects such as gardening or decorating and encouraged to take on responsibilities such as health and safety in the home. Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 23 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, 41 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, the interests of the service users are seen as important to the manager and staff, and are safeguarded at all times. EVIDENCE: The home has an experienced manager who is undertaking the NVQ level 4 and Registered Managers Award. She works alongside staff to make sure of good practice. She also has some administration time to complete her management tasks. The operations manager visits the home on a monthly basis to carry out regulation 26 visits. This involves talking to service users and staff about the Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 24 home. A report of these visits is made showing details of any action to be taken to improve the service. In addition to this, the organisation carries out a quarterly service review, as part of its quality assurance programme. This also includes service users, relatives and staff. The home has a service action plan developed from this review. This is available for all visitors to the home and is displayed in the entrance hall. Staff carry out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting, water temperatures and checks on the house vehicle. Maintenance records are well kept. Environmental risk assessments are completed and were up to date. The senior support worker could not locate a current certificate for gas safety in the home. It was therefore unclear if this annual safety check had been carried out. Water temperatures are checked regularly and shower heads and trays are bleached regularly in line with legionella compliance. Accident or incident reports are completed. However, there is no section for follow up action to be taken after any accident or incident. There was no evidence of a system in place where accidents are analysed to see if there are patterns, trends or ways of avoiding future accidents. The home has a comprehensive range of policies and procedures in place. Staff are given a list of these when they first start work, along with information on where to find them. The organisation has just started to give all staff their own health and safety handbook which links with the training they provide. Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 25 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 3 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5 Requirement The organisation must provide each service user with an up to date contract, showing all charges and additional costs. The manager must make sure that each service user has a clear and detailed care plan, which identifies all their needs and how they will be met The manager must ensure that staff’s records are available for inspection. The manager must make sure that staff are trained in the specialist needs of service users, such as epilepsy. The manager must make sure the gas safety test is up to date. Timescale for action 31/03/07 2. YA6 15 31/03/07 3. 4. YA34 YA35 19 18 31/03/07 30/04/07 5. YA42 23 31/03/07 Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 27 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 YA42 Good Practice Recommendations The manager should make sure that accident records are completed with details of any follow up or outcome to the accident. Accident reports should be analysed to identify any patterns and trends. Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. Extracts may not be used or reproduced without the express permission of CSCI Hough Top DS0000001468.V324618.R01.S.doc Version 5.2 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!