Inspection on 25/11/06 for Mansfield Road Short Stay Unit

This inspection was carried out on 25th November 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 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mansfield Road Short Stay Unit 24/11/07

Mansfield Road Short Stay Unit 25/02/06

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 Mansfield Road Short Stay Unit 29a Mansfield Road Blackpool Lancashire FY3 7HZ Lead Inspector Ruth Edgington Unannounced Inspection 25th November 2006 09:45 Mansfield Road Short Stay Unit DS0000064782.V312889.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 Mansfield Road Short Stay Unit DS0000064782.V312889.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. Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mansfield Road Short Stay Unit Address 29a Mansfield Road Blackpool Lancashire FY3 7HZ 01253 477666 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) Blackpool Borough Council Mrs Barbara Mary Crouch Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service is registered to accommodate a maximum of 4 service users who fall within the following categories: LD (learning disability) PD (physical disability) 25th February 2006 Date of last inspection Brief Description of the Service: Mansfield Road is a purpose built home situated in a residential area and within reach of local amenities and shops. The home can provide accommodation for a maximum of 4 adults who have a learning disability and require respite care (short stay). The period of stay depends on the needs of the individual resident and their relatives. The accommodation consists of two single bedrooms on the first floor and a single bedroom on the ground floor, all of which have en-suite toilet and bathing. There is also a self-contained flat on the ground floor, which can be used for an emergency placement and also to build up skills of service users who wish to return to living independently in the community. In some cases the support given to the service user accommodated in the flat may be from the external agency used by that person. There is also a large lounge, kitchen-dining room and a separate toilet on the ground floor. The home does not have a passenger lift; therefore this is a consideration when assessing the suitability of possible service users. The information contained in the home’s Statement of Purpose/ Service User Guide is included in the information provided to prospective service users and their families. This written information explains the care service that is offered, the management and staff and what the service user can expect if he or she decides to stay at the home. Information received prior to the visit (25/11/06) showed that the fees for an over night stay were £9.03. Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that started at 9.45am on a Saturday morning and took place over 5.30 hours. This included a visit to the home in Coopers Way, which operates in conjunction with Mansfield Road. Service users are able to stay in either home depending on their needs and availability of accommodation at that time. The homes are managed by the same manager, deputy and the staff group work between the two homes, depending on which service users are receiving care at any one time. On the day of the visit there were two service users being accommodated in this home, and one service user who was in the process of moving over to Coopers Way at their request. Prior to the visit the registered manager completed a pre-inspection questionnaire, which provided information about the service users, staff and other information, which assisted in assessing how the home was meeting the National Minimum Standards. Comment cards had been sent out prior to the visit and in total six relatives and five service users, completed and returned these to express their views about the service. As part of the visit the records of the two service users in the home that day were looked at in detail, staff records and a sample of other relevant records were also looked at. Discussions took place with the manager and staff on duty and a tour of the home was undertaken. Communication with the service users varied greatly, however evidence was gained through observations made and the very positive interaction with the two residents who were in the home at the time. From observations made, comments received and written documentation examined, the information has been put together to produce this report. The Pharmacy Inspector undertook a Random Visit to the home on the 6th November 2006. The findings were looked at as part of this visit in order to assess what steps the manager had taken to comply with the requirement and recommendations made. What the service does well: Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 6 This home is extremely well managed and the staff group are very committed and work together to ensure that the service users enjoy their stay and have all their needs met. The total inclusion of all those involved with the individual service users was very evident from the records seen and the comments made in the questionnaires received. The manager said that the individual ”Link workers” (member of staff responsible for an individual service user) work with the families to ensure that everyones needs are met. Comments received from relatives were very positive. One relative said that they never worried when they went away as they knew that the service user was well looked after. Another commented that the service user always came home happy, clean and well fed. “Every thing is excellent at “Mansfield Road.” The visit was undertaken in a very warm, friendly atmosphere and the service users displayed a genuine affection towards the manager and staff. Staff spoken to confirmed that they enjoyed their work and felt supported by the manager. Staff training is given priority to ensure that the staff obtain the experience and knowledge required to meet the different and changing needs of the service users. What has improved since the last inspection? Since the last visit the manager has gained the qualifications required for her position, which ensures that a qualified and competent person manages the home. The appointment of a deputy manager has been a positive step in assisting the manager to ensure that the service operates at a high standard for the benefit of the service users and staff. The manager stated that consultation groups throughout the service have been formed to ensure that the service users have a greater involvement in how the service is delivered. There has been more involvement with the local community, which enables the service users to maintain existing links and form new ones. It also enables the local community to be involved and provide them with a greater understanding of the needs of the service users. Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 7 The issues raised following the visit by the Pharmacy Inspector on 6th November 2006 in relation to the medication procedures have been addressed in order that medicines are handled safely and effectively for the health and well being of the service users. 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. Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The admission and assessment procedures are clear to ensure the care needs of the service users are met. EVIDENCE: The records of two service users who were in the home were looked at and were found to contain very comprehensive assessment information, which had been obtained before any admission took place. The admission procedure included introductory visits over a period of time and assessments made during that this time helped the service user, relatives and staff to decide if the service can meet the service user’s needs. The written assessments seen confirmed that the involvement of the individual service user’s carer at home. Evidence was seen that service users and their relatives had been informed in writing that the home could meet the assessed needs. One of the service users was having their first stay on the day of the visit and had settled in well. Staff spoken to were able to demonstrate their understanding of the individual needs of the service users accommodated. Mansfield Road Short Stay Unit DS0000064782.V312889.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 &9 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. There is a clear and consistent care planning system in place, which ensures that the service users’ needs, aspirations and goals are met. EVIDENCE: On examination of the two service users’ files it was found that they contained detailed information in the Guest Profile document, which included information about their personal, social, emotional and health needs. A care plan had been complied from this information with the involvement of the service user and their family. The service users are very much involved in all decisions that affect them and they are consulted at all times. The care plans show the level of support and assistance being provided to service users with their decision-making. The records also included risk assessments, which enable the staff to give support in encouraging service users to maintain their independence. Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 11 In the case of one service user communication was difficult, but with the assistance of their family the staff had gained information of what certain actions meant and how they should respond in each circumstance. Following each stay the staff complete an ‘Information Sharing Booklet’, which gives the family feedback on what sort of a stay the service user had. The document also gives the family the opportunity to make any comments that they have about the service provided. The home operates a system of ‘Link Worker’ who as part of their responsibility for the care of individual service users are also responsible for liaising with individual service users and their families once a month to update service users file to identify any changes and ensure that their needs continue to be met. Mansfield Road Short Stay Unit DS0000064782.V312889.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): All the above standards were looked at. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Opportunities for development and community participation are addressed in the care plans, ensuring that people have a lifestyle that meets their individual needs and expectations. EVIDENCE: From discussions with the manager and staff on duty it was clear that they understood their role in encouraging independence and promoting the service users’ personal development. Staff recognised the importance of working very closely with the relatives in order that the needs and wishes of the service users were met appropriately. The service users had arrange of activities available to them, which included television, music, videos and board games. Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 13 One of the staff had commenced an “Out and About” booklet, which identified facilities available within a three-mile radius of the home, which service users could visit and become involved in, if they wished. The home had their own transport, which enabled the service users to get to the different venues much easier. Activities were arranged to meet individual wishes and abilities. One service user was going to the pictures that afternoon to see the film “James Bond”, whilst the other service user was being taken out that evening. Both service users were to be accompanied by the number of staff required to ensure that their needs were met. The two homes in the service operate together and service users can choice which to use depending on availability of rooms. Their choice often is dependent on who is in the home at that time, as they develop friendships with other service users. Sample menus were looked at and these confirmed that service users were provided with a varied and healthy diet and a degree of choice. A working group had been formed which included, service users and staff, to look at devising new menu’s. Details of individual preferences and dietary needs were recorded on the service users’ care plan. Information seen in regard to one service user indicated that they required a special diet and appropriate information was available, which included recipe books for their specific needs. Meals times are flexible to met individual needs and what activities the individual was involved in. In the main service users at weekends usually have Brunch as this enables them to have a lie in if they wish. One service user who got up near to lunchtime made it very clear what they wanted to eat and this was provided. The manager and deputy have attended a series of training on diets etc, which staff are to attend later and which will ensure that through the knowledge gained the dietary needs of the individual service users are met appropriately. Mansfield Road Short Stay Unit DS0000064782.V312889.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 Good. This judgement has been made using available evidence including a visit to this service. The health and personal care that service users receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Shortfalls in the medication procedures have been addressed in order to ensure the health and wellbeing of the service users. EVIDENCE: Throughout the visit, observations were made of the support that was given to the service users to maximize their privacy, dignity and independence. The records of the two service users present during the visit were looked at and contained very comprehensive information in regard to their physical and emotional needs and the amount of support that they require. Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 15 The manager stated that a working group was looking into the policies relating to equality and diversity, however from discussions during the visit evidence was gained that staff had an understanding of the equality and diversity needs in relation to the service users. One service user was from an ethnic background did not have any specific needs in relation to this. From the documentation seen, discussions with staff, comments received from relatives and observations made during the visit, evidence was gained that the service users were receiving the personal support that they needed. Comments received from one relative indicated that they felt that the care and facilities were excellent. Another said that the service user “loves the staff and is always happy when at the home “ The findings of the random inspection carried out by the Pharmacy Inspector were discussed and the manager was able to demonstrate that the requirements and recommendation made as a result of that visit had been addressed and appropriate action was being taken to ensure that the practices in the home protected the service users at all time. Evidence seen confirmed the action taken. The two service users in the home at the time of the visit were not taking any medication at that time. Mansfield Road Short Stay Unit DS0000064782.V312889.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. The arrangements in place for handling complaints ensure that people feel confident that their complaints will be listened to and taken seriously. Safeguarding Adult Procedures for dealing with and reporting incidents were satisfactory ensuring the people are adequately protected. EVIDENCE: Evidence was seen to confirm that the complaints policy and procedure was clear, accessible and met the requirements of the standards. It was very unlikely that the majority of service users would be able to make a formal complaint, but from comments made by the relatives it was clear that they were aware of the procedure and would do so on their behalf. One relative stated that everything was excellent at Mansfield Road, including the staff and they had never had any complaints. Comments received from relatives were very positive and confirmed that the staff acted upon any concerns that they brought to their attention. Staff were able to demonstrate that they were aware of individual behaviour changes and gestures that may indicate if a person was not happy and was not able to communicate verbally. Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 17 Staff were given guidance around “ Awareness of Abuse” through the NVQ (National Vocational Qualification) in care and the Learning Disabilities Award Framework (LDAF). There have been no complaints received by CSCI (Commission for Social Care Inspection) or referrals to POVA (Protection of Vulnerable Adults) in the time that the home has been open. Mansfield Road Short Stay Unit DS0000064782.V312889.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 & 30 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The service users live in a comfortable, homely and safe environment. EVIDENCE: The home has been opened for just over a year. The facilities provided are excellent and at the time of the visit the home was found to be warm, clean and free from any obvious hazards. Comments received from one relative indicated that they t that the bedrooms were too large, however this comment was because they felt that if there were more bedrooms more people could be accommodated. Other relatives commented that the home was immaculate and the standards were excellent. During the visit undertaken by the Pharmacy Inspector it was recommended that a lockable facilities should be provided for service users who keep their own medication. The manager confirmed that they were in the process of Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 19 making arrangements to ensure that one piece of furniture in each bedroom was lockable. Discussions were underway to have doors linked to the fire alarm system, as they would prevent any accidents and make it safer for the service users who find it difficult to understand why doors cannot be left in an open position. Arrangements had been made for a local group to carry out work to landscape the garden area and maintain it, in order that the service users can spend time in safe and pleasant grounds. Mansfield Road Short Stay Unit DS0000064782.V312889.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 &36 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. There was little evidence available to confirm that the robust recruitment procedures of the local authority had been complied with to ensure that people using the service were protected. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. EVIDENCE: The staff files kept in the home included a check list of the documentation received as part of the recruitment process, however it was not clear when the CRB (Criminal Records Bureau) and PoVA (Protection of Vulnerable Adults) declarations had been requested and received and who gave permission for staff to commence working with a PoVA declaration whilst awaiting their CRB declaration to be received. Whilst the organisation has a very robust recruitment procedure in place there was very little evidence of this at the home. Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 21 All new staff are inducted through LDAF and evidence was seen of the training undertaken and planned for the future. The training programme ensures that the staff employed by the home are competent and well trained to meet the needs of the residents. One staff member had undertaken a course in sign language to enable them to communicate more effectively with service users if needed. The staff work in both homes in the scheme and staff records are kept at Coopers Way. Of the eighteen staff employed, nine had achieved a minimum of level 2 NVQ (National Vocational Qualification). Evidence was seen of staff undertaking regular supervision and appraisal but not in line with the requirements. The manager confirmed that they had identified this has an issue for improvement and it was being addressed. Documentation was seen to confirm this. Comments received from staff spoken to confirmed that they felt supported and included in all aspects of the service users care. Mansfield Road Short Stay Unit DS0000064782.V312889.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): 37,39,42 & 43. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the service users. EVIDENCE: The leadership from the manager was very good and staff confirmed that they felt valued in their role. The manager confirmed that she had a very committed team, which ensured that the needs of all individual service users could be met. Since the last visit the second home in the scheme has opened for which the manager is also responsible for the day-to-day running. The opening of the second home at Coopers Way has been time consuming, however the manager was confident that with the assistance of a deputy manager who took up post in July of this year, any short fall identified during the visit could be rectified, Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 23 in order that the management team and staff continued to provide an excellent service. Since the previous visit the manager has achieved the required qualifications to ensure that a competent and qualified person manages the home. Comments received from relatives confirmed that they were satisfied with how the home was managed and the support that they received. The health and safety of the service users was protected by the policies and procedures in place in the home. Evidence was seen that confirmed that staff received mandatory training in relation to these issues. The representative of the Responsible Individual, visits on a regular basis, however copies of their report, which should be completed on a monthly basis were not being sent to the CSCI. This is a requirement under Regulation 26 of the Care Homes Regulations and must be addressed. Mansfield Road Short Stay Unit DS0000064782.V312889.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 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 4 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 x 36 2 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 x x 3 x Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 25 Yes 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 YA20 Regulation 13(2) Requirement The registered person must ensure an accurate record of medicines administration is made. The registered person must ensure that evidence is available in the home to confirm that a robust recruitment procedure has taken place before staff commence employment. The registered person must ensure that monthly visits are carried out to the home and a copy of the report sent to the Commission for Social Care Inspection. Timescale for action 13/12/06 2 YA34 17 31/01/07 3 YA43 26 31/01/07 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 YA20 Good Practice Recommendations The medicines handling policy should be reviewed and updated to include all key issues. DS0000064782.V312889.R01.S.doc Version 5.2 Page 26 Mansfield Road Short Stay Unit 2. 3. YA20 YA36 Lockable facilities for storing medicines should be provided for service users who self medicate. All staff should receive formal supervision at least six times per year. Mansfield Road Short Stay Unit DS0000064782.V312889.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Mansfield Road Short Stay Unit DS0000064782.V312889.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!