Inspection on 16/02/07 for Kenneth House

This inspection was carried out on 16th February 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kenneth House 16/12/05

Kenneth House 15/08/05

Kenneth House 27/01/05

Kenneth House 12/08/04

Kenneth House 27/02/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Kenneth House 121 Raeburn Avenue Eastham Wirral CH62 8BD Lead Inspector Beate Roth Key Unannounced Inspection 16th February 2007 1:00 Kenneth House DS0000018903.V317512.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 Kenneth House DS0000018903.V317512.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. Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kenneth House Address 121 Raeburn Avenue Eastham Wirral CH62 8BD 0151 327 3680 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) angie.kemp@wirral.autistic.org Wirral Autistic Society Mrs Helen Louise Rudd Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th December 2005 Brief Description of the Service: Kenneth House is registered to provide personal care for four adults with autism. The home is a two storey semi-detached property located in a residential area. On the ground floor there is a lounge with patio doors leading to a large garden, dining room, kitchen and a toilet. On the first floor there are four single bedrooms, an office/staff sleep in room, a bathroom and a shower room. Parking is available on the main road. Kenneth House is close to local shops and to public transport services. Wirral Autistic Society who have several care homes for adults with a learning disability in the area run the home. Wirral Autistic Society provides a range of services and facilities, which are fully utilised by the service users, accommodated at Kenneth House. At the time of the inspection, the weekly cost for the service ranged from £894.00 to £1256.00. A copy of the statement of purpose, which describes the services offered at Kenneth House, is made available to relatives and social workers. The service users guide to the home is made available before a service user comes to live at the home and the content is discussed with them, where appropriate, to ensure their understanding. Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 4 hours and is based on a visit to the home, information received about the service since the last inspection and by questionnaires completed by the manager, service users’ relatives and healthcare professionals. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the manager. A tour of the home was undertaken. I spoke with staff and made observations of staff delivering care to service users. A sample of financial records held on behalf of service users at the head office of Wirral Autistic Society were seen. What the service does well: What has improved since the last inspection? What they could do better: Improvements need to be made to the recording practices around complaints. A record needs to be made of all complaints and the action taken to investigate them. Evidence that the fire alarm has been regularly serviced is to be forwarded to CSCI in order to demonstrate that the fire alarm is working effectively. Advice from the fire service is to be taken regarding the current Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 6 means of securing the main exits from the home so as to ensure that the safety of service users is safeguarded at all times. It is recommended that the manager sign records of medication given on an as and when needed basis to manage behaviour as this clearly demonstrates that there is management overview. It is recommended that an evidence based recording system be put in place to identify that the Skills for Care workforce training targets have been met and any learning needs identified for staff. It is recommended that a system be introduced for renewing criminal records bureau checks to ensure that service users are fully safeguarded by the recruitment and retention procedures of the home. 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. Kenneth House DS0000018903.V317512.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 Kenneth House DS0000018903.V317512.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, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The assessment processes are good and this ensures that the service is only offered to individuals whose needs can be met at the home. There are good arrangements in place to ensure that service users and their representatives can be confident that the home is right for them before moving in. The contracts/terms and conditions could better support the interests of service users. EVIDENCE: No new service users have come to live at the home since the last inspection. The initial assessment process indicates that the assessment process covers all of a service users’ needs including their communication, religious and cultural needs. New service users are assessed by the manager for the home and by a representative from day services. The manager visits a prospective service user where they are living. Information is gathered from the service users’ carers, social worker and any other relevant agencies. If a service user moves to the home from another home run by Wirral Autistic Society, an assessment of the service users needs is undertaken. A discussion with the manager indicated that new service users could make a number of visits to the home to get to know the service, meet the staff and other service users. These visits are planned in accordance with the needs of Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 9 the new and existing service users. Parents/carers and representatives from placing authorities are also able to make visits to the service. This ensures that decisions about the placement can be carefully considered and there is a clearer understanding of what can be expected from the home. A sample of contracts/statement of terms and conditions between the home and the service users were seen. These documents contain the required information. Representatives of two service users have signed these documents. It continues to be recommended that where service users are unable to understand contracts/statement of terms and conditions, that where appropriate, a representative of the service users who is an individual independent of the home agrees the contract meets the service users best interests. In this case due consideration must be given to the provisions of the Mental Capacity Act 2005 in reaching decisions in the best interests of the service user. Kenneth House DS0000018903.V317512.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. Good care planning systems ensure that the assessed and changing needs of service users are well considered with service users being encouraged to make decisions about their lives. The service users need for independence is balanced with any risks to their wellbeing. EVIDENCE: A sample of service user plans were examined and these contained clear information to enable staff to provide appropriate support around day-to-day living and personal goals. A review had taken place within the last 6 months. The documentation available from reviews indicated that the service user, their relatives, social worker and other relevant individuals are invited to contribute to the reviews. A questionnaire returned by a relative and a one by a GP stated that they are satisfied with the overall care provided at the home. The service user plans indicated that service user’s independence is promoted, Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 11 in accordance with their abilities. Risk assessments are available in order to safeguard service users and promote their independence. Reactive plans, which detail behaviour management strategies are available and guide staff in ensuring they support service users in the correct way. Service users are encouraged to contribute towards the running of the household. Service users go shopping and help with meal preparation in accordance with their abilities. Service users’ views are obtained through their individual key workers. Service users are able to make their views known about the day care services offered at a service user run advocacy group, which meets every week. Communication passports are in the process of being completed for service users. This initiative will be a valuable tool for obtaining the views of service users. The policies and procedures have been made available in formats that make them more accessible to service users where this is possible. This allows service users to become familiar with guidelines for how staff should endeavour to support them in all aspects of service users daily lives. Kenneth House DS0000018903.V317512.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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. Service users are able to take part in appropriate activities that provide opportunities for their educational, social and personal development. Links with the local community are well promoted. The daily routines and arrangements for promoting relationships with family and friends are good and support service users. Varied and wellbalanced meals are provided in homely surroundings. EVIDENCE: Service users attend day services from Monday to Friday, where they are provided with opportunities for social, educational and communication support and development. Service users have a timetable of activities, which has been drawn up to meet their needs, skills and individual preferences. Some of the opportunities available are horticulture, craftwork, community work experience, drama and physical education. Daily living skills are taught at day services by appropriately trained staff, and by care staff within the home on a Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 13 daily basis. The home accesses Speech and Language Therapy services for service users who may need such support. This along with using a picture system to communicate with service users who may have limited verbal communication skills demonstrates a commitment to ensuring service users have a say and that they can understand and contribute to decisions made at the home that affect their lives. A discussion with the manager and staff indicated that there are opportunities for service users to become involved in the local community in accordance with their wishes. Records showed that service users were choosing not to engage in many activities outside the home at the weekends or during the week. The manager reported that they are working on encouraging service users to take part in more activities. The home has access to private transport and there is access to bus services. Staff and records indicated that family links and friendships are promoted. The arrangements for contact with family are written into the service users’ care plans. Discussions with staff and via direct observations provided evidence that the home’s routines are flexible and fit in with the needs and wishes of the service users. The records inspected also indicated that service users receive the support they need in their daily lives in order to make decisions and encourage independence. Care plans recorded the dietary requirements of service users. Advice is obtained from a dietician if this is required. A record is kept of food provided to service users. The records showed that well-balanced and varied meals are provided which meet the cultural background of the service users. Overall well balanced, nutritious meals are provided. Kenneth House DS0000018903.V317512.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The health and personal care needs of service users are well met. Service users are protected by the home’s procedures and policies for the management of medication. EVIDENCE: Records clearly detail the support service users need with their personal care. The routines of service users are documented and provide good guidance for staff on how to support the service users. Observations indicated that staff, promote the privacy and dignity of service users. Consistency and continuity of support for service users is provided through the key worker system. Staff receive training on promoting privacy and dignity during their induction. This sets the out the importance of ensuring people is treated with dignity and that their rights are promoted. Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 15 Records of reviews and a discussion with a service user indicated that service users have access to medical/health care professionals as needed. Service users are supported to attend health care appointments. Service users are supported and facilitated to take control of and manage their own healthcare in accordance with their abilities. A questionnaire returned by a relative indicated that they are consulted about the care provided and kept informed of important matters. A questionnaire returned by a GP indicates that the home communicates clearly and works in partnership, medication is appropriately managed and staff have a clear understanding of the needs of service users. A medication procedure is available which provides clear guidance. Medication is stored securely. The records of training indicate that staff have been trained in the safe handling and administration of medication. Following the last inspection the manager has been ensuring that all staff clearly understand the medication procedure by discussing the procedure on a regular basis at team meetings. A selection of medication administration record sheets and corresponding medication were inspected and found to be in order. It is recommended that the manager sign records of medication that is given on an as and when needed basis to manage behaviour as this clearly demonstrates that there is management overview. Kenneth House DS0000018903.V317512.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. Good staff training and policies and procedures are in place to ensure that service users views are heard and appropriate action taken. The practices at the home provide protection for service users form abuse. Improvements need to be made to the recording practices around complaints. EVIDENCE: Information is available to enable a complaint to be made by a service user or on their behalf, by an advocate. The complaint procedure includes the timescales for dealing with each stage of a complaint. The complaint procedure is displayed on the service users’ notice boards. The procedure is available in different formats to reflect the abilities of service users. The manager reported that one complaint had been made since the last inspection. A record of this complaint had not been made. A discussion with the manager indicated that appropriate action had been taken to investigate this. No complaints have been made to CSCI since the last inspection. Staff are aware of how to respond to a complaint. Staff reported that they continually find out the views of service users in accordance with their abilities and attempt to resolve any issues that arise. A copy of Wirral Borough Council’s adult protection procedure was available at the home. All staff who work at the home have received training in the adult Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 17 protection procedures. A member of staff spoken with had a good understanding of the adult protection procedures. This means that service users are supported by staff who are aware of and understand the importance of protecting vulnerable people. The financial records were examined and it was evident that the home’s policies and practices with regards to service users’ money and financial affairs safeguard service users. Monies held at the home, on behalf of service users are checked daily by staff, audited by the manager on a monthly basis and by the representative of the registered provider at their monthly visits. Receipts are being maintained and records are signed by staff. Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The home in general provides a safe, clean and pleasant environment for service users. EVIDENCE: The premises provide a comfortable environment for service users. The appearance of the home has improved following decorative and maintenance works. One bathroom has been made into a shower room and the second bathroom has been re-decorated. The kitchen flooring has been replaced. Service users bedrooms are personalised and promote their lifestyle choices. The home was clean and odour free at the time of the inspection. Steps have been taken to ensure the safety of service users at the home. The manager reported that thermostatic mixing valves with lockable temperature controls are fitted to the bath and bathroom sink and have been fitted to the shower. The manager reported that the water temperature is checked on a regular basis. All radiators now have low surface temperature coverings in Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 19 accordance with a risk assessment. Window restrictors are fitted and regularly checked. The records relating to the checks of the gas safety and electrical wiring were seen and were in order. A sample of fire safety check and inspection records were examined and in general found to be in order. Evidence that the fire alarm has been serviced at regular intervals was not available. The certificate available was dated 20/09/2004. Evidence that the fire alarm has been regularly serviced is to be forwarded to CSCI. The fire exits to the home are kept locked in order to ensure the safety of the service users. A member of staff has access to the key at all times. The advice of the fire service needs be taken regarding this arrangement in order to ensure that this safeguards the wellbeing of service users in the event of a fire. Steps are to be taken to address any risks to the welfare of service users that are identified. Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. Service users are supported by competent staff who have access to good training opportunities. Staff are appropriately deployed to meet the needs of the current service users. The recruitment practices safeguard service users. EVIDENCE: An examination of the rota indicates that there are two members of staff on duty at all times apart form at the weekends when there are periods where there is only one member of staff on duty. A member of staff spoken with said that the staffing levels are sufficient and enable activities to be undertaken outside of the home. At previous inspections staff have said that it would be beneficial to have two staff on duty throughout the weekends. The manager is currently reviewing the staffing arrangements at the home with a view to encouraging the service users to take part in more activities outside of the home. There is a network of support provided by Wirral Autistic Society for lone workers. Lone worker risk assessments are available. There are currently four permanent staff working at the home with absences being covered by permanent or bank staff. Bank staff have been recruited to work for Wirral Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 21 Autistic Society to cover absences in the homes if needed or to provide support within the day care service. A comprehensive induction and foundation training programme is provided to permanent staff. The training covers health and safety matters, adult protection, equal opportunities, working with adults with autism and promoting the rights of the service user. The induction and foundation training programmes have been developed in accordance with the National Training Organisation training targets. This training is also provided to bank staff so as to ensure that they are appropriately trained should they need to be deployed. It is recommended that an evidence based recording system be put in place to identify that the Skills for Care workforce training targets have been met and any learning needs identified for staff. It is understood that this information is recorded for some aspects of this training. Staff are encouraged to undertake an NVQ in caring for adults with a learning disability. At present all 4 permanent staff hold a relevant NVQ. Specialist training is provided to staff to assist them to support service users as appropriate. Training is provided to staff around equal opportunities. There has been no new staff employed at the home since the last inspection. A sample of records of recruitment were seen and indicated that all the required information was available. At present there is no system in place for routinely updating CRB checks. The manager reported that this is in the process of being addressed. Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The welfare of service users is supported by a well run home and by the quality assurance systems in operation. EVIDENCE: Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 23 The manager of the home has had several years experience of management in a care setting. The manager has an NVQ Level 4 in care and management and other relevant qualifications. The manager has undertaken periodic training to maintain and update her knowledge skills and competence. A member of staff interviewed reported that they consider their views regarding the running of the home are sought and listened to. A clear complaint procedure is available. Staff meetings are held every month. There are a range of quality assurance systems in place. Wirral Autistic Society is accredited by the National Autistic Society which carries out an inspection of services provided. Wirral Autistic Society conducts an internal audit of the society as a whole on an annual basis. The views of service users are obtained by key workers and the manager. Questionnaires are sent to service users’ relatives regarding how the home operates. Visits to the home by the representative of the registered provider are made. These reports are made available to CSCI. The manager carries out a monthly house check of all reccords and the premises. The day service also provides a forum for service users to give their views on the services provided there. It is understood that questionnaires for health and social care professionals are in the process of being devised. Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 25 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 YA22 Regulation 22 Requirement The registered persons must ensure that a record is made of all complaints and the action taken in respect of such complaints. The registered persons must ensure that the safety of service users is promoted at all times. Advice from the fire service must be taken regarding the current means of securing the main exits from the home. Steps are to be taken to address any risks to the welfare of service users that are identified. The registered persons must provide evidence that the fire alarm is regularly serviced. Timescale for action 16/02/07 2. YA24 23 16/02/07 3. YA24 23 16/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 26 No. 1. Refer to Standard YA5 Good Practice Recommendations It is recommended that an individual independent of the home agree that the contract/statement of terms and conditions meets the interests of the service users in accordance with the wishes and abilities of the service users. It is recommended that the manager sign records of medication that is given on an as and when needed basis to manage behaviour. It is recommended that an evidence based recording system be put in place to identify that the Skills for Care workforce training targets have been completed and any learning needs identified for staff. It is recommended that a system be introduced for renewing criminal records bureau checks. 2. YA20 3. YA35 4. YA34 Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Kenneth House DS0000018903.V317512.R01.S.doc Version 5.2 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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