Inspection on 08/11/06 for House Of Light

This inspection was carried out on 8th November 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

House Of Light 10/01/06

House Of Light 19/07/05

House Of Light 13/10/04

House Of Light 25/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 House Of Light 13 Allerton Park Leeds West Yorkshire LS7 4ND Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 8th November 2006 12:30 House Of Light DS0000001469.V319092.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 House Of Light DS0000001469.V319092.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. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service House Of Light Address 13 Allerton Park Leeds West Yorkshire LS7 4ND 0113 268 1480 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) Catholic Care (Diocese of Leeds) Miss Aileen Donnelly Care Home 6 Category(ies) of Learning disability (6) registration, with number of places House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: The House Of Light provides accommodation for 6 male and female service users with learning disabilities aged over 35. The home does not provide nursing care. The home is based in a large detached private house situated in the residential area of Allerton Park. The house is adjacent to other private dwellings and blends into the suburban area. The accommodation is on four floors with 6 single bedrooms based on the lower ground, 1st and 2nd floors. There are three reception rooms based on the ground floor providing alternative communal seating and activity areas. The home has extensive gardens and lawn, which complement the overall appearance of the home. The local shops and community facilities are a short walk away in the Chapel Allerton area. The home also has its own minibus. Fees for one week are £627. People living at the home and staff prefer the term ‘residents’; therefore this term has been used throughout the report. House Of Light DS0000001469.V319092.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 A pre-inspection questionnaire was completed by the home and this information was used as part of the inspection process. Comment cards were sent to relatives and healthcare professionals and these responses have also been included in the inspection report. One inspector carried out a site visit which started at 12.30pm and finished at 6.30pm. Feedback was given to the manager the day after the inspection. During the visit the inspector looked around the home and spoke to residents, staff and the registered manager. Care plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. What the service does well: What has improved since the last inspection? Staff and the manager have been doing NVQ awards and the learning from these programmes has provided them with more knowledge and made them look at their own practices to make sure they are in line with good practice guidance. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 6 Improved lighting has been provided in one bedroom and this has created a safer environment for the resident. 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. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 7 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 House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 8 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): 2, 3, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission’s process is good because staff and management make sure the home is suitable before they make a decision, and prospective residents have opportunities to visit the home and talk about the placement. EVIDENCE: One resident moved into the home earlier in the year, all others have lived there for at least three and a half years. The recent admission process was looked at during the inspection. The manager and a staff member from the home had visited the prospective resident and carried out an assessment before they decided if the home could meet their needs. A social care professional completed an assessment and this confirmed the type of support the resident required. The resident said she visited the home a lot and stayed over before she decided to move in. A formal review, which confirmed the placement was very successful, was held six weeks after the resident had moved into the home. Residents living at the home discussed, during one of their residents’ meetings, how they felt about the prospective resident moving in. The meeting minutes confirmed everyone was happy. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 9 The resident who recently moved in said they were very happy living at the home. Staff and the manager said the admission process had gone extremely well and the home was successfully meeting the needs of the resident. Residents’ files contained placement agreements and these contained the service terms and conditions and the cost of fees. One resident was over the age of 65. The resident, staff and the manager all said the home was suitable and able to appropriately meet their needs. Currently the home is registered to provide care to people between the ages of 18-65. The manager agreed to apply for a variation of registration. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care planning process is central to the care that is provided and staff work hard to make sure residents’ needs and aspirations are met. Residents are encouraged to make decisions and say what should happen at the home. EVIDENCE: Care records for three residents were looked at. There was good information in each plan of care and there was guidance on how individual needs should be met. For example ‘I clean my own room with a little supervision, I love the garden and walk around it.’ Two of the residents talked about what they liked doing and their care plans reflected this. Staff talked about how they supported residents and again this was reflected in the care plans. Daily records identified when residents had received support and also where there were any changes in support needs. New care plans were written if House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 11 appropriate and existing care plans were reviewed as needs changed. Care plans had been reviewed monthly. Each resident has a ‘person centred’ annual review. As part of the reviewing process residents and staff prepare a pictorial wall display that identifies what the resident enjoys doing and what they want to do in the future. One resident said she had sat with staff and found pictures and items of things she liked doing and was making a display to go on the wall. She said she liked talking about what she wanted to do and was enjoying getting ready for her review. One review report stated that during the review ‘everyone agreed that all the things had been done that had been requested at the last review’. This demonstrates that goal setting is properly monitored. Several residents have lived at the home for many years. Their care files contained a lot of information, some of which was not relevant to their current needs and it was difficult to find the current information. One file contained a support plan dated ‘00, person centred plan dated, ‘03, individual plan dated ‘02 and goal plan dated ’02. The manager agreed to archive some of the old information. Residents talked about making decisions, which included deciding what to do and where to go out. Resident meetings are held and these provide opportunities to talk about what happens at the home. Residents have been responsible for chairing their meetings. One resident spoke about stopping some evening activities because he didn’t want to go anymore, another resident said he was doing more on an evening and had just started a new evening activity. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are very happy living at the home and have an active and fulfilling lifestyle. The range of recreational opportunities for each resident is excellent. EVIDENCE: Residents spoke very highly about the home. The following comments were made, ‘I like it here, staff are nice, they help me, I go out a lot with staff, it’s good because I say what I want to do at my review, I can see my family when I want, I like doing things around the house with staff.’ Residents talked about doing different things which included having parties at the home, singing on the karaoke, going out on the minibus, going to church, baking and gardening. One resident talked about going shopping and on holiday. He said he was very busy doing different things. Another resident said she liked going out with staff. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 13 Four weeks of daily records were looked at and these confirmed that residents led a fulfilling and active lifestyle. Recreational activities included, theatre trips, going to local shops and Leeds town centre, disco, baking, dance class, party, craft fair and family visits. The home’s activity room had a lot of different activity and craft materials, games and puzzles. There was also evidence of residents being supported with independent living skills such as hoovering, washing up, sweeping, general cleaning and shopping. Staff talked about contact with family and friends. One resident talked about her family visiting her at the home and said they had recently attended a party. Another resident’s family member was attending an annual review. Staff talked about the service being structured to make sure residents have a fulfilling lifestyle but also a flexible service to make sure residents can choose what they do. Each resident attends external day care services but day care packages vary depending on resident’s individual needs. For example one resident only attends on an afternoon, and another resident has one day off because she wanted to go with staff to do the main food shopping. Staff and the manager talked about ensuring everyone received a good quality service that was balanced and fair. They demonstrated an awareness of equality and ensured all residents received opportunities to participate in recreational activities, had individual time with staff and access to the community. Daily records confirmed that all residents received a lot of input from staff and where possible family were also involved. A relative comment card stated they were satisfied with the overall care and ‘the care and attention has been second to none.’ The evening meal was very pleasant, residents and staff talked about their day and this was obviously a social occasion that everyone enjoyed. Residents and staff plan the menus on a weekly basis. Two weeks menus were sent with the pre inspection material and these were varied and nutritious. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Everyone receives high quality person centred care that focuses on personal development and promotion of choice. The home has good systems in place to make sure residents receive the right support from healthcare professionals. Information should be recorded about residents’ preferences for medication administration and the records should be checked more carefully to make sure medication administration is safe. EVIDENCE: Care plans had information about how personal care needs should be met. For example one stated, ‘ I can wash and bath myself.’ There was also evidence that independence was promoted and residents were encouraged to develop. For example, one resident had set clear goals to develop independence and go shopping unaccompanied. Each stage was set out and agreed with the resident and staff, after assessment it was agreed satisfactory progress had been made and it was time to move onto the next stage. This was very good practice and there was evidence that the programme was successful and the resident had developed their level of independence. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 15 Staff said all residents use community healthcare services and this includes dentist, chiropodist and GP. One resident said she tells staff when she is unwell and when she needs to go to the GP staff go with her. Daily records stated that residents had attended healthcare appointments within the last four weeks. Residents’ weight had been monitored monthly and a record was maintained. A GP comment card stated that they were satisfied with the overall care provided within the home and carers were well informed of residents needs and medical conditions, they confirmed that residents visit the surgery. Medication records were looked at and were completed correctly. One resident had been prescribed antibiotics. The number of tablets prescribed and the number of tablets remaining corresponded with the medication administration record. Two medication records had spelling errors. The medication administration record stated Resperidal, the medication label stated Risperdal. Although this is a minor error it demonstrates that staff are not checking that the medication labels correspond with the medication administration record. This is a very important task when carrying out the safe administration of medication. The manager agreed to contact the pharmacist and ask if they could provide printed medication administration records. No residents self medicate and care plans do not contain any information about medication administration. There should be information that consents to care workers administering medication and personal preference for administration. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory procedures are in place and residents will report their concerns to staff and management. Systems are in place to make sure residents’ finances are safeguarded. EVIDENCE: The pre inspection questionnaire confirmed that the home has a complaint’s and an adult protection procedure, and staff and the manager have attended adult protection training. The manager said the home had not received any complaints for a number of years. The home has a complaint’s book to record any complaints and a copy of the procedure was available in the home. Residents said they were happy to talk to staff and the manager if they are unhappy. Financial records were looked at. All financial transactions were recorded and receipts were obtained for any purchases made. Residents have individual bank accounts. The manager said all residents go to the building society to withdraw money. Residents and staff sign for transactions. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is pleasant, well maintained and residents are very comfortable in their surroundings. EVIDENCE: A tour of the building was carried out. All communal areas and bathrooms were visited and the majority of bedrooms were seen. The home was clean and tidy and there were no odours. Decoration, furniture and furnishings were of a high standard. The garden is well maintained and a very pleasant area that residents freely access. Bedrooms were personalised and each room had a lot of items that reflected individual preferences. Photographs of family and friends had also been mounted on the wall. This is good practice and demonstrates that everyone is encouraged to make their rooms homely. The last inspection identified that the lighting level in one bedroom was too low, better lighting has since been provided. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 18 There are four main communal areas, kitchen, dining room, lounge and activity room. The residents were using all the communal rooms and were seen to walk freely around the home. There were photographs, pictures and ornaments in communal areas which helped enhance the homely environment. The stair carpet was worn in places but the manager had already identified that this needed replacing. The new carpet had been ordered and they were waiting for a date for it to be fitted. An audit of the grounds identified that a handrail was required for health and safety reasons. This was being pursued by the manager. This demonstrates that the environment is properly monitored and items are replaced when required. In the laundry there was a sink and a bar of soap for washing hands but no anti bacterial hand wash or paper towels. The registered manager must make sure hand washing facilities are appropriate to prevent the spread of infection. The home does not have a call bell. The manager and staff said they did not think a call bell would be beneficial and they could not think of any past event when it would have been an advantage. Radiators are not guarded and again the manager and staff did not feel this posed a risk to anyone at the home. The manager should complete environmental risk assessments to ensure risks are appropriately assessed and managed. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team work very well together and everyone works hard to provide good individual care. The team all have a good understanding of the home’s aims and objectives which has resulted in each resident receiving a good standard of care. Staff feel well supported and systems are in place to make sure everyone receives the right training and supervision. EVIDENCE: The staff team consists of the manager, deputy, three care staff and three overseas volunteers. The home has a low turnover of staff and many staff have worked at the home for a number of years. The volunteers work alongside the staff team and are included in the staffing levels. Each worker has clear roles and responsibilities. Staff work 9:00am- 10:00pm on a Saturday and a Sunday. This provides better opportunities to organise longer outings. One care staff had completed the NVQ level 2 award and two care staff had almost finished the award. Volunteers come from overseas on a voluntary House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 20 placement and stay at the home for a year, therefore they will not have an opportunity to complete the NVQ award. When the two care staff finish their award the home will have 50 of care staff trained to NVQ level 2, although it will never be able to achieve above this target because the volunteers are included in the staffing numbers. Staff who had done the award said the training had helped them improve their practice and had made them think more about what was good care practice. Individual training records for all staff were sent with the pre inspection questionnaire. These confirmed that all staff had completed a range of training courses. Training included, medicine administration, adult protection, fire training and food safety. Staff said the team works very well and communication was good. They have a daily handover where information is passed on to staff who are starting their shift. Staff regularly attend meetings, within the four month period before the inspection, three staff meetings had been held. One volunteer that recently started work at the home talked about the recruitment and induction process, and confirmed they had attended an interview with the volunteer agency and had a telephone interview with the manager of the home. The volunteer had completed an induction book and said her induction included basic training, shadowing staff and reading care plans. Recruitment records for two volunteers were looked at. All the relevant information was available and had been translated into English. Staff receive 1-1 supervision at least six times a year. In addition to formal supervision, staff said the manager provides informal daily supervision. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has good leadership skills and promotes a high standard of care. Systems are in place to make sure the quality of the home is monitored but copies of the reports should be made available to the Commission to confirm that monitoring of the home is ongoing. EVIDENCE: The registered manager has started the Registered Manager’s Award and anticipates she will finish by June 2007. She said the course was going very well and it made her think about the general management of the home. Once a month the provider visits the home and looks at the general conduct, these visits are called Regulation 26 visits. Copies of reports from these visits should be sent to the CSCI but only two reports have been received in recent House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 22 months. The reports contained sufficient information to demonstrate that the provider is monitoring the quality of the home. The manager said the area manager visits the home on a regular basis and carries out monthly checks but copies of the reports were not available for inspection. The visitor’s book confirmed that the area manager frequently visits the home. Residents meeting minutes confirmed that residents’ views were taken into account. They had talked about problems around the home, activities, menu ideas, what they had been doing and what they enjoyed. This is a good method of monitoring quality in the home. Individual running records provided good detail of what each resident had been doing. However, the records were not signed, therefore it was not possible to tell who had written each record. Accident records were looked at and they described in sufficient detail what had taken place and who had witnessed the incident. The pre inspection questionnaire stated that policies and procedures were available and regular maintenance and health and safety checks by external agencies were completed at the home. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 4 5 3 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 3 25 X 26 3 27 3 28 3 29 2 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 3 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 2 X 2 3 X House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13 Requirement Timescale for action 31/12/06 2. YA29 13 3. YA30 13 4. YA37 9 The manager must make sure safe medication administration systems are in place. This relates specifically to ensuring medication administration records are correct and care plans contain information that consents to care workers administering medication and personal preference for administration. The manager must complete 31/12/06 environmental risk assessments to ensure residents are free from avoidable risks. This relates specifically to unguarded radiators and a call bell system. The manager must ensure 31/12/06 systems are in place to control the spread of infection. This relates to hand washing facilities in the laundry. The manager must complete 20/03/07 level 4 NVQ in management. (carried forward from 31.12.05) The registered person must ensure the copies of the regulation 26 reports are sent to the CSCI. DS0000001469.V319092.R01.S.doc 5. YA39 26 31/12/06 House Of Light Version 5.2 Page 25 6. RQN Care Standards Act; Section 15 The manager must apply for a variation of registration that enables them to provide care to one service user over the age of 65. 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA41 Good Practice Recommendations The manager should remove the information that is not relevant from the care plans. The manager should make sure staff sign the running records when they make an entry. House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 26 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 House Of Light DS0000001469.V319092.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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