Inspection on 19/09/07 for Montague Drive

This inspection was carried out on 19th September 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 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Montague Drive 21/09/09

Montague Drive 13/09/06

Montague Drive 17/01/06

Montague Drive 08/06/05

Montague Drive 25/01/05

Montague Drive 27/01/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Montague Drive 20 Montague Drive Leeds West Yorkshire LS8 2PD Lead Inspector Valerie Francis Key Unannounced Inspection 19th September 2007 10.00 Montague Drive DS0000001482.V351459.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 Montague Drive DS0000001482.V351459.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. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Montague Drive Address 20 Montague Drive Leeds West Yorkshire LS8 2PD 0113 240 0062 0113 2400062 montagudrive@c-i-c.co.uk www.c-i-c.co.uk. Community Integrated Care 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) Mrs Joanne Pamela Martin Towey Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 13th September 2006 2. Date of last inspection Brief Description of the Service: The South Yorkshire Housing Association owns the property at Montague Drive. The care and services are provided by Community Integrated Care which is a registered charity caring for people with special needs. Montague Drive is a detached bungalow located within 2 miles of Leeds City Centre and is at the top of a quiet cul-de-sac. There are a wide range of shops and leisure facilities within easy reach of the property. The home has 4 bedrooms. All are single rooms and have a washbasin. The current scale of fees is £1,048.38p to £1,080.47p weekly. Additional charges are made for chiropody, hairdressing, newspapers and personal items. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk One inspector carried out a key inspection looking at the standards, which is highlighted in the report. The inspection was carried out over two days the 19th of September 2007 at 9.30am until 4.30am. The inspection was completed on the 28th after further discussion with the manager. The purpose of this inspection was to make sure the home was providing a good standard of care for the people living there, and to monitor progress on the requirements and recommendations made at the key inspection on the 13th September 2006 and the random inspection carried out on the 20th January 2007. The people who live at the home will be referred to, as the people who use the service; therefore this will be used throughout the report. The methods used at this inspection included looking at care records, observing working practices and talking with people who use the service, visitors and staff. Information gained from AQAA (Annual Quality Assurance Assessment) and the service history records were also used. Before the visit, survey questionnaires were sent out to the home for visiting relatives and people who use the service and health care professionals who have input in the care of people living at the home. Completed survey information was returned from people who use the service, three from relatives, one not completed and three from health care professionals. This information has also been used in this report. Feedback was given to the manager at the end of the inspection. I would like to thank everyone who returned survey questionnaires and for the hospitality and assistance during the inspection process. Requirement and recommendations made during this visit can be found at the end of the report. What the service does well: Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 6 Staff said “that there has been many changes in the home which has improve the atmosphere in the home and the care for the people living there.” The manager was said to be “supportive and approachable”. The people who use the service said “ staff look after us”. And we get out a lot. “ We can choose what we want to do.” Staff make sure that people have regular and varied activities, which are recorded in their daily diary. Each person’s room is individual to them and shows their interests and preferences are catered for. The manager and staff team work together to make sure people have the care to meet their needs. What has improved since the last inspection? What they could do better: The registered person must review the arrangements for the home’s vehicle. This must include opportunities to access the vehicle and financial arrangements. The people supported or their representatives must be involved in this process. The washing machine should have a suitable disinfecting/sluicing programme. Due consideration should be given to resolve this good practice recommendation to ensure that infection control is not breached. The complaint procedure should be made available to people who use the service, in a place that is accessible to them. The procedure must also be readily available to visitors and staff. The registered manager must ensure that all people using the service have had a nutritional risk assessment, to makes sure that they are not at risk. Matters relating to the shortfalls in the environment must be addressed to make sure that the environment is in a good state of repair. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 7 All effort should be made to ensure that all parties involved in people’s care are invited to any review of their care, if this is the wish of the person who use the service. So that data protection and confidentiality is not breached, information about people using the service must only be written in their individual record file and kept secure and not be part of the staff minutes. 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. Montague Drive DS0000001482.V351459.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 Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives now have sufficient information available to them to make an informed choice about the home. Anyone wanting to use the service has a full assessment before a place is offered. EVIDENCE: The Statement of Purpose and Service User Guide have been produced in an easy read format, using large print and photographs. A copy of the service user guide was placed in each persons file; this should also be made available where people and their families and visitors can have access to them. There is still some ongoing issue with the contribution people are making with regards to the home’s vehicle. There was no evidence of any agreement having been made with regard to this arrangement. People have lived at the home for sometime therefore there was very little recent evidence available for the admission process. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 10 The manager talked about the admission process in detail which she said includes making sure the admission process is tailored to meet the needs and wishes of the people who use the service. Any potential admission in the early stages involves other professionals, completing assessments and talking to the manager, and visits made to the person wanting to use the service, by the staff undertaking the assessment. Each person who uses the service has been given an agreement that sets out the home’s terms and conditions, which includes the fees charged for their placement. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6.7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments, in the main, provide clear detailed instruction on how people’s needs are to be met. People are encouraged to make decisions and say what should happen at the home. EVIDENCE: Several different documents were seen that provided information about care needs. The information described what people like and dislike, how their needs should be met and any potential risks. It was evident on talking to the staff that they had very good knowledge of people who use the service and their individual care needs. People’s plans of care were person centred. It was evident from one of the care files that the manager was working with staff to improve written information. It was also clear from one of the people’s care plans that if diet intake was an Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 12 issue, there was clear plan of action to be taken to meet this need. However, despite this there was no evidence that a nutritional risk assessment had been done to assess the persons dietary needs or evidence of the involvement of a dietician. Generally information seen provided very specific details about how people are looked after, which were consistent with what had been recorded in care plans and needs assessments. Review meetings were being held, and although one persons advocate who was visiting said that she had attended a review meeting, there was no evidence in care file that she had been invited to these meeting. It was evident that reviews of care plans and risk assessments are completed every month. Staff spoken to thought everyone worked hard to promote people’s rights and believed people who use the service were given opportunities to have control over their own lives. The relative who responded was positive about the standard of care that is provided but said, “There was large turn over of staff that was felt led to lack of knowledge of the people in their care”. Responses from health care professionals were also positive and made comments such as “Staff listen to and respect resident’s views.” ” They provide a comfortable and caring home for residents.” Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,6 & 17. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Effort is made for people who use the service to lead an interesting life and have the opportunity to be involved in a variety of activities. EVIDENCE: People who use the service are involved in various activities each week. This ranges from an activity and leisure service, meals out, shopping, drives out, to going to the pub and walks. Activity also takes place in the house during the evenings by getting involved in household activity such as cooking. People are encouraged to meet up with friends and to keep in contact with their families. Staff were seen to support people with courtesy and thought for their dignity. Staff said it was important to make sure people are as independent as possible. They said they are encouraged to get involved in household tasks and to make drinks and snacks for themselves. There was plenty of social interaction between the staff and people who use the service. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 14 It was evident throughout the inspection that people are being cared for in an atmosphere that is relaxed. Meals are planned with people where they get the opportunity for choice, and it was apparent that a good variety of food is available and staff try to make sure there is a good selection of fresh produce, which suits the needs of the people. People are given the opportunity to get involved in doing the weekly shopping. The lunchtime meal was relaxed and made into a social occasion for people. A service user who has some behaviour that challenges others at meal times was supported properly. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported properly with their personal care needs. Health care support is provided in a way that meets individual needs. There are good policies and procedures in place for dealing with medication. EVIDENCE: People are supported with their personal care needs in private and with dignity likes, dislikes and preferences are acknowledged. Care plans and assessments provided specific information about health and personal care needs. There is detailed information in people’s care file of any health professionals people need to see. These included, GP, dentist, psychiatrist and physiotherapist. Records are kept of any health appointments and their outcome. People are accompanied on their appointments. Staff have had training to meet people’ specialist health needs, for example, dementia. The manager and staff said they thought the home was good at Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 16 consulting healthcare professionals when they want advice and support. One health care professional said the Learning Disability team is informed promptly when service user’s needs change. Each person has a daily records diary, which has records of all daily events concerning the person, which includes input from external healthcare professionals. The home uses a monitored dosage system for medicines. All staff have undertaken a twelve week course on safe handling of medicines. Staff have access to the organisation’s medication policy procedure. There are good systems in place for ordering and checking of medication with a clear audit trail for any unused medication returned to the pharmacy. The medication administration record (MAR) sheets were checked and showed that codes are used when medication is not given. One person had not had her medication although a code was used; there was no written explanation of the omission. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service or their representative’s concerns are listened to and acted upon. People are protected from abuse by the home’s policies and procedures on adult protection. EVIDENCE: People indicated in their survey information that they knew who they would talk to if they were not happy. Relative surveys stated they knew how to make a complaint. The home has not received any complaint within the last twelve months. People have been given a copy of the home’s complaint procedure which is in a pictorial and easy read format that explains to people what to do when making a complaint if they were not happy. This however, is kept with their care file in a locked drawer in the office. This information must be accessible to people. The home’s complaints procedure is not available to visitors or staff if they want to make a complaint using the procedure. Staff have attended adult protection training and were familiar with adult protection procedures. There is ongoing discussion in team meetings with regards to Safeguarding Adult procedures. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 18 There is a copy of the Department of Health document No Secrets and the Leeds multi-agency Adult Protection Procedure in the home but not readily available to staff, for them to refer to if an incident occurred or brought to their attention. Personal allowance records were looked at. All financial transactions were recorded and receipts were obtained for any purchases made. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is on going redecoration and replacement of bedroom furniture. People have the opportunity to choose new furniture and fitments and have their room decorated to their taste. EVIDENCE: A tour of the building was carried out, accompanied by the manager. The premises appeared to be spacious for the needs of the present group of people living there, providing sufficient room for them. Some people’s bedrooms have been redecorated. On the day of the inspection the home had a delivery of furniture and fitments that had been ordered by three of the people, they each had a specialist bed. The styles of the rooms show people’s interests and personality. The home was clean, to a good standard and warm throughout. Work had started in the dining room to resolve the damp on one of the walls, the Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 20 manager said when was dried out, it would be redecorated. Some shortfalls in the building were observed during the inspection of the building; There were obvious signs of wear and tear of the building and the hall carpet was stained and needed replacing. The decoration in the bathroom and the floor covering in the toilet also needed replacing, the toilet pottery was showing signs of wear. There were no shades to any of the light fitments seen in the bathrooms and the electrical ventilators in these areas needed cleaning. The issue of the washing machine being replaces with a sluice cycle still needs to be given due consideration so that infection control is not compromised. It is acknowledged that the manager staff and people who use the service are working hard to create a homely and domestic environment for people. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35. Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. People are protected by the home’s recruitment procedures, the staff team work well together and everyone works hard to provide good individual care. Staff feel well supported, there are systems are in place to make sure everyone receives the right training and supervision. EVIDENCE: There are staff on duty throughout the day and night. There are usually two or three staff on the morning and afternoon shifts. At night there is one waking member of staff. There is an on call arrangement within the organisation for one of the registered managers from a home to be on call for any emergency. The manager has two shifts per week where she is supernumerary and can attend to her management role. Recruitment records were inspected for two members of staff one of whom had recently been recruited. It was evident that interviews are held; references and CRB (Criminal Record Bureau) POVA (Protection Of Vulnerable Adults) checks are obtained before staff start work, and checks are made to make sure staff are eligible for work. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 22 There is a Matrix training plan with good records of staff’s training and when their updates are due. The manager carries out monthly assessments to make sure training doesn’t get missed. Staff spoken to said they had good training and support from the manager. The organisation sends out their annual training plan to the home, which is comprehensive and covers all the training needs of the staff. One member of staff has achieved an NVQ (National Vocational Qualification) in level 2. Two staff are currently working towards this qualification. During discussion with staff they felt, that they had a good team and the manager was very supportive, and felt communication and teamwork within the home was good. Staff said they receive supervision from the manager every six weeks. There is a daily handover where information is passed on to staff who are starting their shift. Staff meetings are held once a month. Staff said these were good opportunities to discuss anything that was relevant to the home. The minutes from the meetings were detailed and a good source of information for staff who were not present. During this meeting each person’s care is discussed with information included in the minutes of the meeting. The manager was reminded that information about people must be written in their personal notes and kept securely. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, the interests of the people who use the service are seen as important to the manager and staff, and are safeguarded at all times. EVIDENCE: The home has an experienced manager who is undertaking the Registered Managers Award with plans in place for her to start NVQ 4. She works alongside staff to make sure of good practice. She also has some administration time to complete her management tasks. Relatives and staff were very complimentary about the manager and thought the home was well managed. Staff said the manager was organised, approachable, good at allocating tasks and making sure things were followed through. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 24 The home is visited and supported by external line management on a monthly basis to carry out regulation 26 visits. People who use the service and staff are involved in the visit; they are given the opportunity to talk about the home. A report of these visits is made showing details of any action to be taken to improve the service. A quality audit of the service is carried out as part of the quality assurance programme, which involves people who use the service, relatives and staff. Health and safety checks around the home such as fire alarms, emergency lighting, water temperatures and checks on the house vehicle are carried out. Maintenance records are well kept. Environmental risk assessments are completed and were up to date. The manager could not locate a current certificate for electricity check in the home. The manager said she would locate this from the housing association and send a copy to the CSCI. The home has a comprehensive range of policies and procedures in place, which was accessible in office. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 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 2 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 3 X 2 X 3 X X 3 X Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 26 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 YA17 Regulation 13 Requirement Timescale for action 19/12/07 2. YA13 The registered manager must ensure that all people using the service have had a nutritional risk assessment, to makes sure that they are not at risk. 26/12/07 12, 16, 17 The registered person must review the arrangements for the home’s vehicle. This must include opportunities to access the vehicle and financial arrangements. The people supported or their representatives must be involved in this process. Previous timescale 31/03/07 Matters relating to the shortfalls in the environment must be addressed to make sure that the environment is in good state of repair. So that data protection and confidentiality is not breached, information about people using the service must only be written in their individual record sheets and kept secure and not part of the staff minutes. 3. YA24 23 28/12/07 4. YA10 17 28/11/07 Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA30 Good Practice Recommendations The washing machine should have a suitable disinfecting/sluicing programme. This is outstanding from the previous inspection. Due consideration should be given to resolve this good practice recommendation to ensure that infection control is not breach. 2. 3. YA6 YA22 All effort should be made that all parties involved in people’s care are invited to any review of their care, if this is the wish of the person who use the service. The complaint procedure should be made available to people ho use the service, in a place that is accessible to them. The procedure must also be readily available to visitors and staff. Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Montague Drive DS0000001482.V351459.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!