Inspection on 17/05/06 for Josephine Butler

This inspection was carried out on 17th May 2006.

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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Josephine Butler 20/04/10

Josephine Butler 04/02/10

Josephine Butler 25/03/09

Josephine Butler 10/07/08

Josephine Butler 19/09/07

Josephine Butler 20/01/06

Josephine Butler 27/07/05

Josephine Butler 15/12/04

Josephine Butler 23/09/04

Josephine Butler 14/04/04

Josephine Butler 17/06/03

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

CARE HOME ADULTS 18-65 Josephine Butler 34 Alexandra Drive Liverpool Merseyside L17 8TE Lead Inspector Leila Mavropoulou Key Unannounced 17th May 2006 09:30 Josephine Butler DS0000025114.V288541.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 Josephine Butler DS0000025114.V288541.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. Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Josephine Butler Address 34 Alexandra Drive Liverpool Merseyside L17 8TE 0151 727 7877 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) Mr Harold Smith Philip David Wade Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21) of places Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents between ages of 16 - 64 years To accommodate one named service user over the age of 65 years Date of last inspection 20th January 2006 Brief Description of the Service: Josephine Butler House is a large detached property set in its own grounds in the Sefton Park area of Liverpool. It is short walk from Sefton Park, Lark Lane, shops, pubs and public transport. The home provides care and personal support to younger people between the ages of 18-65 years that have mental disorder. The accommodation is provided on three floors with the communal areas: lounge, dining room, conservatory, games room and quite room on the ground floor. All the service users’ accommodation is provided in single bedrooms. Service users are able to access the first and second floor by the passenger lift. The service users at the home require little assistance with personal care except for supervision and encouragement. The home is staffed twenty-four hours a day by a Registered Mental Nurse and support workers. The service users are encouraged by staff to access various community facilities and to maintain their independence. The weekly fee is currently £400 per week and service users are given written terms and conditions showing what is included in the weekly fee. Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted seven hours over two days. During the inspection six service users were spoken to and four members of staff and the plus the registered manager. A sample of service users care plans and risk assessments were inspected as well as staffing and other health and safety records. Also, tour of the building was made. What the service does well: What has improved since the last inspection? The dining room chairs have been replaced and there is overall improvements being made gradually to improve the physical environment. Staff training is ongoing to improve staff knowledge and understanding of service user needs through formal training and the micro teaching sessions given by the manager and deputy manager. Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 6 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. Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 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 Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” The service admission procedure ensures that prospective service users know that their needs would be met. However, the service must adhere to the policy fully to ensure that prospective service users needs would be met. EVIDENCE: The Statement of Purpose is easy to read and provides information about all aspect of the service provided at Josephine Butler House such as: staffing level, philosophy of care, activities etc Inspection of recent admissions to the care home showed that the nursing staff from Josephine Butler assess prospective service user needs before offering a placement at the care home. This is to ensure that the service has the necessary facilities and staffing level etc. to provide the necessary care and support to the service user. However, two of the service users files examined showed did not have a service user pre-admission assessment. Service user files seen showed that written terms and conditions is given to service user showing the weekly fee and what items are included in the fee. Restrictions placed on service user regarding the service rules on smoking, alcohol and drugs are included in the terms and conditions. Prospective service users are encouraged to visit the home to meet other service users and staff to get a “feel” for the home. The visits will vary depending on individual needs and preferences. This was evidence in one of Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 9 the service user file. It is recommended that details are kept of service user visit which could be used when developing the service user initial care plan. Josephine Butler DS0000025114.V288541.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): 6,7,8,9,10 “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” The service user needs are met and demonstrated in the service user plan. However, the service user plan must incorporate the service user social and emotional needs to enable these areas to be monitored and reviewed formally by the nursing staff. EVIDENCE: The service users have detailed care plans and risk assessments showing how their assessed needs would be met and how identified risks would be minimised. All staff can read and understand the service user plans, as they do not include nursing abbreviation. Currently, the service user plan does not include details of how the service would support the service user to meet their social and emotional needs, nor does it take into consideration any differences the service user may have regarding: gender, religion, race, disability etc. The service user plans inspected showed that where possible the service user has been consulted about the content of the plan. The plans are reviewed at regular intervals, usually every three months. The registered manager should review formally the service user plan at least every six months with the service user, their family/representative and any others health professional that are involved in the delivery of the service user care. Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 11 Observation during the inspection and discussion with service users and staff clearly showed that the service users make decisions over their daily lives. Service users continue to have a weekly activity plan, which show planned and actual activities that the service user engaged in. This includes activities that the service users engage independently or with staff. All of the service users manage their own finance, make decisions about maintaining contact with their family and choose the level of participation in activities either in the community or in the home. Monthly service users meetings are held and generally, the same service users attend the meeting. Staff support service users to take responsible risks as identified in their service user plan. Some of service users have kettles in their bedroom for which risk assessments have been developed to minimise risks. The service has a missing person policy and individual times are given to each service user before the home’s missing person policy is implemented. Service users records are kept in a secure place and discussion with staff confirm that they understand the home’s policy on confidentiality of information. Josephine Butler DS0000025114.V288541.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): 11,12,13,14,15,16,17 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” Staff support the service users to develop new skills and personal relationships to maintain their social and emotional well being. EVIDENCE: Service users are responsible for maintaining their bedrooms with support from their key worker to ensure that service user maintain their daily living skills. This includes being responsible for their laundry. Observation and discussion with service users show that they make decisions over all aspect over their daily lives, such as choosing to spend time on their own in their bedroom or in the communal areas with other service users. Some service users choose to attend college to improve their knowledge and skills. Currently, four service users attend college/day centre where they are learning skills such as: computer skills, painting, gardening etc. The service is located close to shops, pubs, library, etc. Observation during the inspection showed that service users access these regularly throughout the Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 13 day independently and inform staff when they leave the building. The service is close to a main road where service users could access a number of buses. Most service users have a bus pass. Service users weekly activity sheets are maintained to demonstrate the range of activities that service users access. Service users are able to access a wide range of entertainment in the community, where they have the opportunity to meet others that do share the same disability. Currently, the service does not contribute towards service users holidays. Observation and discussion with service users show that they are supported to maintain interests they had before coming into the care home and to develop new ones as described above. Staff support service users to maintain contact with their family and friends. Some service users regularly spend overnight stay with their family or for longer periods if they wish, whilst others have shorter visits depending on their individual circumstances. Where necessary staff would accompany the service user on their visit as identified in their service user plan. The service has an unrestricted visiting policy and service users are able to choose where to see their visitors. All parts of the home are easily accessible to service users. The service has a large garden to the rear of the property, which is used by service users during the warmer weather and there is large tarmac area to the front of the property, which is used as a parking area for staff and visitors. Service users are provided with a key to their bedroom door to promote their privacy. The locks on the service user bedroom door can be open by staff in an emergency. Discussion with service user indicated that they are very happy with the food provided at the care home. A record is kept of all food provided to service users and there was evidence of a choice of meal being offered to service users. The registered person must ensure that appropriate foods to meet individual service user dietary needs, as identified in the service user plan are purchased and made available to service user, as one service user required decaffeinated coffee and tea which was not available in the home. Discussion with the catering staff showed that they are aware of service user likes and dislikes as well as specific dietary needs when they are informed by the nursing staff. Josephine Butler DS0000025114.V288541.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 good. This judgement has been made using available evidence including a visit to this service.” The staff monitor service users health to ensure that their health needs are met by accessing appropriate support and advice from other health professionals when necessary. EVIDENCE: Observation of service users showed that they require little assistance with personal care except for prompting and supervision as evidence in the inspection and the pre-inspection questionnaire. Josephine Butler does not have any aids currently except for a call system as the service users are mobile and do not require any assistance with transferring. Most staff have attended training on moving and handling. Observation of staff assisting service user with personal care showed that service user’s right to privacy and dignity are respected. Discussion with service users and staff confirm that they choose when to go to bed and the time they get up. Observation and discussion with a service user show that service user’s key worker provides assistance with personal care as identified in the service user plan. Some of service user continue to have additional support from the Community Psychiatric Nurse and has regular Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 15 review of their medication and metal health needs by the psychiatrist. The staff monitors closely the health of the service users and where necessary advice is sought from the service user GP or other relevant health professional. Where necessary staff from the care home would accompany service users to outpatient appointment and visit to the chiropodist, optician or dentist. The chiropodist visits the care home every two months. The nursing staff at the care home currently administers the service users medication. The home uses a monitored dosage system and records are kept of all medication received into the care home, administered and returned to the pharmacist. Inspection of service user medication records showed that medication records are not being maintained accurately as medication is not signed as given when administered as evidenced on two service user medication records. Josephine Butler DS0000025114.V288541.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 good. This judgement has been made using available evidence including a visit to this service.” Service users are encouraged to raise concerns by using the home’s complaints procedure and the regular service user meetings. EVIDENCE: The service has a complaint procedure, which is displayed in a prominent position. A suggestion box is available to enable stakeholders to raise their concerns or make comment about the service. The service has received no complaints in the last twelve months. The service has various policies and procedures in place to protect service users and staff from all forms of abuse. Josephine Butler DS0000025114.V288541.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): 24,25,26,27,28,29,30 “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” The registered provider is gradually improving the physical environment of the care home to improve the quality of facilities for service users. EVIDENCE: All parts of the home are easily accessible to service users and the building was clean, bright and free from malodour. The registered provider in recent months has replaced all of the dining room chairs and the bedroom furniture. However, most of the bedrooms and bathrooms need redecorating and some require new carpet. The building is in keeping with the local community and the premises is well suited for the service user group as most of the bedrooms are very large and the home is within a short walking distance to the local shops and public transport. Regular fire tests are carried out and fire equipment is serviced in accordance with the local fire authority recommendations. All accommodation is provided in single bedrooms. Many of the bedrooms are personalised with service users belongings that reflect their interests. All bedrooms have a wash hand basin, call system and windows are fitted with window restrictors. It is recommended that a lockable space is provided in the service user bedroom. Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 18 There are a number of toilets and bathrooms, which are located near the service users bedrooms and the communal areas. However, the bathrooms even though some improvements have been made through laying of new floor covering, they still need upgrading to improve the quality of facilities offered to service users. The communal areas in Josephine Butler are large, bright and airy which could be used for a variety of purposes. There is a large lounge, a smoking lounge, conservatory, dining room and a games room. The service has a passenger lift to enable service users to access the bedrooms on the first and second floor of the building. The lift is serviced regularly to ensure the safety of service users. All of the bedrooms have a call system, which was tested and found to be in working order and response time of staff to the call was good. Currently, none of the service users have a disability that requires specialist aids to promote their independence and safety. The laundry equipment is situated in the basement which is easily accessible to service users. Policies and procedures are in place to minimise the spread of infection. Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 group meet service users health and social needs. However, this could be improved through improved formal supervision to identify individual staff training needs. EVIDENCE: Discussion with staff and observation of the staff rota show that the staffing level is adequate to meet the assessed needs of service users. There are both male and female staff on duty at all times to reflect the gender mix of the service user group and to to ensure that their personal care needs would be met by someone from the same gender if they wish. The registered manager should identify in the service user plan any preference a service user may have in relation to gender of the staff that asssit them in their activities of daily living. In recent months staff have been attending various training courses such as: first aid, food hygiene, moving and handling and physical and verbal aggression to maintain their knowledge and skills. Discussion with the qualified staff indicated that the support workers are good in informing them of changes in service users behaviour, which are noted and closely monitored to ensure that advice is sought from specialist health professionals as soon as possible to promote the good health and safety of the service user and others in the care home. The staff recruitment records is generally good except that Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 20 the home has not obtained their own Criminal Record Bureau check for members of staff and have used their existing Criminal Records Bureau check from previous employment. The registered person must ensure that Josephine Butler obtain a copy a Criminal Record Bureau check for all staff. Discussion with the registered manager and staff confirm that informal supervision takes place. However, these are not recorded. This is an ongoing requirement and the register person must ensure that they are able to demonstrate that staff are appropriately supervised and have the necessary skills and knowledge to perform their roles and responsibilities. The pre inspection questionnaire show that 40 of the staff have completed their NVQ level 2 in care. The maintenance of records in the care home has improved generally. Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41,42,43, “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” The quality of service provided at Josephine Butler is improving. However, continuous improvements is required as identified in this report to promote the health and safety of service users. EVIDENCE: Discussion with the registered manager indicated that the quality of care provided at Josephine Butler is improving through improvements in the service user plan, the activities provided to service users, staff training and the reduction is staff turnover even though there has been some problems in recent months as evidenced in the pre-inspection questionnaire. The registered manager is nearing completion of his NVQ level 4 management award. However, he has not attended any further training in the last twelve months to maintain his clinical knowledge. The health and safety of service users are promoted as evidenced in the records inspected. Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 22 The registered person must ensure that records are accurately maintained as evidenced in service user care plans/risk assessments, medication records, review of policies and procedures. The service has a quality assurance system in place but this has not been reviewed to show any improvments in the service provided at Josephine Butler. However, in recent months this has been intermittent. The service promotes the health and safety of service user through ensuring that all equipment used at the care home are checked and serviced at regular intervals in accordance with the relevant regulating body e.g. regular fire drill and fire checks take place. The fire equipment was last service in 14/04/05, last fire drill 24/03/06. The registered person must ensure that fire drills are carried out at various times during the day to ensure that all staff receives fire training. The fire logbook showed that weekly fire checks are carried out. The central heating was checked/serviced in July 2005 and the gas installation was checked and approved by the engineer in 5/12/05. The electrical engineer visit was planned for the 26th May to check the electrical wiring. Records are kept of accidents to staff and service users at the care home and where necessary the Commission is informed. There are clear lines of accountability with the external management of the home. The registered manager indicated that receipts are kept of all payment for expenditure at the care home for accounting purposes. The home has a current Public Liability Insurance. Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 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 3 2 2 3 3 4 3 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 2 25 3 26 2 27 2 28 3 29 2 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 2 3 3 2 3 Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 24 NO Are there any outstanding requirements from the last inspection? 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 YA2 Regulation 14 Requirement Timescale for action 30/07/06 2 YA6 15 The registered person must ensure that service user needs are assessed before they are offered a place at the care home. 30/07/06 The registered person shall review the service user plan with the service user or their representative at regular intervals. The service user plan must include details of how service user social and emotional needs are to be met and to highlight any specific needs/differences the service user may have e.g. Religion, race, sex, disability etc. The registered person must ensure confidentiality of service user medication is maintained by reviewing its “handover” book. The registered person shall provide appropriate food to promote individual service user dietary needs. The registered person must ensure that an accurate record of service user medication is maintained to promote their health and welfare. DS0000025114.V288541.R01.S.doc 3 YA10 17 30/07/06 4 YA17 12 30/07/06 5 YA20 12 & 18 30/07/06 Josephine Butler Version 5.1 Page 25 6 YA24 23 The registered person must 30/07/06 ensure that the home is in a good state of repair internally and externally through a planned maintenance and renewal programme such as: replacement of carpets in service users bedroom, refurbishment of bathrooms and decorating of service users bedrooms. The registered person is required to forward an action plan for the decorating/replacement of the service. This is outstanding from the last inspection 20/01/06. The registered person must ensure that the bathrooms and toilets are decorated. The registered person must ensure that all staff have a Criminal Record Bureau check, which is obtained, by Josephine Butler care home. The registered person must ensure that nursing staff Nursing and Midwifery Council registration number is kept at the care home. The registered person must ensure that all staff are appropriately supervised and a record kept of issues discussed. This is outstanding from the last inspection. The registered person must ensure that the registered manager undertake appropriate training to maintain their knowledge and skills. The registered person must ensure that a report of their monthly visit to the care home is forwarded to the Commission. The registered person must ensure that the service policies DS0000025114.V288541.R01.S.doc 7 YA27 23 30/08/06 8 YA34 18 30/07/06 9 YA36 18 30/07/06 10 YA37 10 30/07/06 11 YA39 26 30/07/06 12 YA40 17 30/07/06 Josephine Butler Version 5.1 Page 26 13 YA41 17 14 YA42 23 and procedure are regularly reviewed. The registered person must ensure that all service users records are maintained accurately. The registered person must ensure that current risk assessments are in place of the entire building. This is outstanding from the last inspection. 30/07/06 30/07/06 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 Refer to Standard YA9 Good Practice Recommendations The registered person should ensure that all service users have some form of identification on their person when they go out of the home. The registered person should include a minimum of seven days holiday for long-term service user outside the home, which is included in their weekly fee to meet all of the requirements of this standard. The registered person should ensure that the registered person has a training budget to enable them to prioritisation of staff training. The registered person should complete their NVQ level 4 Management qualification to satisfy the National Minimum Standards of 2001. 2 YA14 3 YA35 4 YA37 Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Josephine Butler DS0000025114.V288541.R01.S.doc Version 5.1 Page 28 - 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. 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