Inspection on 16/08/06 for Morley House

This inspection was carried out on 16th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Morley House 27/04/05

Morley House 16/11/04

Morley House 11/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Morley House 1 & 2 Morley Square Bishopston Bristol BS7 9DW Lead Inspector Karen Walker Unannounced Inspection 16 August 2006 09:30 th Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Morley House Address 1 & 2 Morley Square Bishopston Bristol BS7 9DW 01275 372109 01275 373151 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) Freeways Trust Ltd Mr Jason Sanders-Harding Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate persons aged 21 - 64 years Date of last inspection 19th October 2005 Brief Description of the Service: Morley House is operated by Freeways Trust Ltd and is registered to provide personal care and accommodation for up to thirteen people who have a learning difficulty. The house is situated in a residential area and blends in well with the local environment. It is built over four storeys and has a basement for storage and laundry use. There is a pleasant garden with seating area. The premises would not be suited to residents who have mobility difficulties, as floors are only accessible via staircases. Morley House is located close to local amenities and shops, which are regularly used by residents. There are also two cats, which live at the property and are looked after by residents. Residents asked said they ‘liked having the cats around’. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fees for this home vary according to need but are in excess of £534.00. Residents are expected to pay for additional items such as holidays or toiletries out of their personal allowance received weekly. This was an announced inspection lasting seven hours. The purpose was to follow up on requirements made at the last visit and to ensure compliance with legislation. Comments from residents, staff and relatives have been included in this report. 4 residents were case tracked and information gained in respect of them. Records relating to individual residents and the running of the home were also examined. A tour of the property was undertaken with the Manager. The required ‘Pre-Inspection Questionnaire’ was duly completed and returned to the inspector. Further, comment cards were received from residents; relatives/visitors; and the General Practitioner mostly stating positive comments regarding the home. The inspector was made to feel welcome and noted a friendly and relaxed atmosphere in the home. The opportunity is taken to thank residents and staff for their time and support on the day of inspection. What the service does well: The manager demonstrated that many positive changes have taken place since the last inspection. The home now has Internet access and one resident said, “I’m getting Internet access in the downstairs lounge so I can download pictures of my favourite television characters”. This will also aid communication links with the accessibility of emails. Positive communication is forged between the home and relatives and the manager has devised a monthly newsletter for each resident to keep relatives abreast of new developments and life at Morley House. Many positive comments were made about the home and staff team with one resident stating, “I like it here I like all the staff and I like all the residents”. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents know that their individual needs will be assessed. EVIDENCE: There have been no new residents since the previous inspection and there are no vacancies within the home. The manager has updated the statement of purpose and residents have a copy of the service user guide in their bedroom. One resident confirmed this. Through case tracking it was noted that a full assessment of need was undertaken and that the relevant care manager was instrumental in planning care appropriately. One resident said, “I was at that meeting and agreed to my plan”. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ needs and goals are reflected in their plan of care. Residents are able to make their own decisions and are consulted on decisions made in the home that affect them. Although residents are supported to take risks as part of an independent lifestyle this must be fully documented to ensure consistency. EVIDENCE: One resident enjoyed talking through his care plan and on examination of other plans it was evident that they reflected current lifestyle and choice. Care plans are devised by the appropriate social services care manager and are reviewed by the staff at Morley on a monthly basis. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 10 Care plans had been reviewed consistently and extra meetings and reviews have been held when necessary to ensure adequate support. Residents and family members have been present at some of these meetings. It is recommended that the resident sign their own care plan and any subsequent reviews to evidence their involvement and ensure continued input. Residents attend regular in-house meetings and choose the agenda. Minutes of the last meeting covered residents’ choice of holiday. A number of residents attend an advocacy group called ‘Our Voice’; Information about this group is displayed on the resident’s notice board, with photos and details of their fortnightly meetings. Evidence of who attends was seen in individual files. One resident who frequently goes out into the community is supported to do so. Agreed protocols and risk assessments are in place to ensure his safety. These are reviewed on a regular basis however discussion was held with the manager about the need to include a risk assessment to manage the risk when he refuses to get into transport. The resident often does not return by the agreed time so the police are regularly involved. Staff are in good communications with the police to ensure that procedures are adhered to. Multi-disciplinary meetings have been held in relation to this issue so that all involved are doing everything they can to prevent unnecessary risk. Risk Assessments are in place but can be improved. It was noted that there were generic risk assessments in place alongside individual risk assessments. One risk assessment limited a person’s choice and freedom to use the kitchen. This was discussed with the manager and immediately addressed. Some other typed risk assessments lacked information to adequately support the person, i.e. ‘can turn on TV but unsure of DVD player, would need support’. Other risk assessments also stated, ‘needs full support’. Any support necessary to minimise a risk must be detailed and adequately recorded. Incident reports show continence management to be a challenge in the home. Risk assessments must be put in place to minimise the damage done to furniture. There are some reactive strategies in place that are necessary and support residents through periods of behaviours that challenge. There are other strategies that the inspector feels are not necessary examples were discussed with the manager. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents have opportunities to take part in appropriate activities and are a Part of their local community. Residents’ rights are respected and they have the opportunity to make and maintain relationships of their choice. EVIDENCE: Residents are supported to attend day centres and partake in their weekly ‘Life Skills Day’ where they help out with certain chores. However it was noted that most areas of the home require deep cleaning and this will be further discussed in standard 30. There were various certificates of achievement displayed in some resident’s bedrooms; these were gained from the day centre. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 12 Residents coming home at the end of the day were pleased to show the inspector new certificates and one said, “I really like it at the day centre, I have done a lot”. There are many opportunities for residents to take part in activities, and with people other than whom they live with. For example, the house holds Karaoke nights, inviting other Freeway’s homes, and residents go to play darts at another house. The home holds fundraising events such as a fete in the Local Park and car boot sales. Holidays are arranged according to the needs and wishes of the residents. One resident said, “I went to Butlins and I really like it there”. Another resident was supported to visit family members abroad and it was noted that advice was sought from the general practitioner regarding the flight beforehand. Morley house is now part of the local neighbourhood’s committee and contribute towards the upkeep of the square. The manager said this makes residents feel more of a part of their community and are now known by their neighbours. Residents confirmed that they can have visitors at any reasonable time and are in close contact with family and friends. Staff are keen to ensure that individuals can choose who visits them and when. This was evidenced through documentation seen. The Internet has been installed and one resident said he is looking forward to using it in the downstairs lounge to download his favourite TV characters. It was noted at the last inspection that there are a few residents who have put on weight or are classified as obese. Staff are aware of this and now monitor weight on a monthly basis. One staff member is working with the dietician and is planning a healthier menu. The manager said that seconds and third helpings were now discouraged. The inspector agreed that staff have a duty of care to encourage a healthy lifestyle. There are also examples of how residents have lost weight and remained stable. Where there have been concerns, professionals have been involved. The fridge was well stocked and there is always fruit available. Some residents assist with the cooking and there is a washing up rota for residents. Residents also enjoy eating out in local public houses, cafes and restaurants. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents receive care and support in a way they prefer and are assured that their physical and emotional needs will be assessed and met. Residents benefit from sound medication practices and are protected by appropriate policies and procedures. The aging and death of residents is addressed and wishes ascertained. EVIDENCE: Morley House accommodates residents with varying levels of need and required support. Some residents have complex needs and are supported appropriately. There was evidence of continence advice being sought as well as psychology input, speech and language therapy, community learning disability nurse and psychiatric input. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 14 The home operates a Key Worker System for each resident who write monthly reports inclusive of monitoring the resident’s health care needs and behaviour. Residents spoken with were aware of who their Key Worker is and their role. It was evident from speaking with staff that they were well aware of residents’ needs. It was documented in residents’ files that any specialised treatment needed has been sought and acted on. This is good practice. Within individual care plans, it was evident that residents receive regular and flexible support for personal care. All five resident’s files looked at had had regular appointments from relevant professionals. The medication administration records were examined for all residents, all were in order. A sample of ‘as and when’ (PRN) medication balances were checked and also found to be order. Staff record the reason for the PRN medication and must gain agreement from the manager before administration. Relevant policies and guidance are in place. There is a checklist; signature list; photos of all residents; side effects; and individual medical histories. There is also a new transfer sheet for relatives to complete if the resident is taken out when medication is due. The manager continues to monitor the competencies of staff to ensure that residents remain safe. This includes observation and training. All residents have leaflets in their personal files relating to their wishes in the event of their death. The leaflets were designed with and for people with a learning disability. This is good practice. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ views are listened to and they are protected from abuse. EVIDENCE: Staff and residents are aware of their right to complain about issues within the home. Sufficient copies of the leaflet ‘Is the care you get the care you need?’ from the CSCI was given to the Manager at the last inspection to use and distribute accordingly. One resident said, “I can tell my key-worker or the manager things if I’m not happy. I like all the staff and all the residents here”. The resident’s complaints file is kept in the office. Inserts are logged and numbered. There have been 11 complaints made since the last inspection. All have been investigated and substantiated and the appropriate action has been or is being taken. The CSCI receive regulation 37 notifications appropriately (notification of incidents etc that affect a residents wellbeing) and is aware that incidents are handled well. There are no current protection issues and the manager confirmed that all staff have received protection training provided by the organisation. It is recommended that the manager and team attend training provided by Bristol Social Services carried out by the Adult Protection Coordinator to ensure they are up to date with current legislation and best practice. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Although residents live in a homely environment it would benefit from being ‘deep cleaned to ensure comfort and safety. Some bedrooms require attention and modernisation to ensure resident choice and comfort. There are adequate shared areas and sufficient bathrooms. EVIDENCE: The inspector took a tour of the environment and found some areas of the house to be ‘grubby’. This included the kitchen and residents bedrooms. Whilst some effort was made to clean the kitchen and cooker during the visit it is required that the home is ‘deep cleaned’ and residents are supported to keep their bedrooms clean. The manager is already aware of the problem and has devised a checklist for staff. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 17 Most bedrooms however were personalised and reflected individual style and choice. One bedroom had damp patches on the ceiling and loose paper on the walls. This room looked jaded with old-fashioned tiling around the sink and old built in wardrobes making furniture choices difficult. This room is in need of redecoration with investigations into the damp patches. It is also recommended that the tiles be removed and the wardrobes modernised. The television in one bedroom sits on the dressing table but is too large to be secure and was observed to be hanging off the dresser. It is a requirement that this TV be made safe and the risk of it falling off and hurting the resident minimised. This was discussed with the manager who will ensure it is made safe. It must also be recognised that although there are high incidents of ‘continence issues’ the house has a pleasant odour and the manager reported that the bathrooms are cleaned twice a day. The downstairs lounge has been decorated some months ago but is still used as a storage area with walls that remain bare. The manager is aware of this and will be putting up shelves and pictures soon. There are photos of residents in collages around the home and the team have tried to add a ‘homely’ feel to place. Residents, with an assessed low risk outcome, have a key for their bedroom. One resident who does not have a key stated “ I like it just the way it is I don’t want a key”. The basement area now requires some redecoration as residents still have access to this area. It was suggested that one of the residents interested in painting and decorating be allowed to ‘help out’. There are adequate bathing and toileting facilities available for the residents and there is a walk-in shower in-situe. The manager said that some residents prefer showers. The office is small but functional and has been redecorated. The washing machine in the basement is often opened by residents whilst in mid cycle, and is in constant use. This is causing problems to the machine and it is recommended that a new industrial machine be bought to cope with the constant use and to have a secure lock on the door. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are protected by a robust recruitment practice and staff are supported to be competent in meeting the needs of the resident group. EVIDENCE: Staff spoken with were clear regarding their roles within the home, including their Key Working responsibilities. It was also evident from residents’ files that staff are aware of resident’s needs and how to deal with arising issues. The manager has a training plan in place suited to meeting the needs of individual residents and will soon be attending training on sexuality and managing challenging behaviour. Records show that staff attend all the relevant statutory training. Staff are supported to undertake a National Vocational Qualification (NVQ) in care and the Assistant Manager has started her NVQ at ‘Level 4 in care’ to further her competencies. The manager said residents are to be involved in the latest round of interviews for Home Support Worker; this is good practice and should be encouraged. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 19 Records kept at the home are robust with staff records examined containing supervision records, personal identification, details of Criminal Record Bureau (CRB) checks, 3 references, induction and appraisal. There are adequate policies and procedures in place to safeguard residents whilst carrying out the recruitment process. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ benefit from a well run home and are confident that their views will be listened to. The health, safety and welfare of residents is promoted and protected. EVIDENCE: The manager has an NVQ in care and has gained the Registered Managers Award (RMA). He continues to update himself by attending various training courses designed to support him in meeting the needs of residents. The manager said he is well supported by his line manager and the inspector was impressed at the detail contained in the regulation 26 reports received by the CSCI on a monthly basis. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 21 ‘Listen to me books’ are in place as part of person centred planning. These books contain details of the wishes and preferences of individuals as well as goals, likes and dislikes. One resident gave the inspector permission to look at his book and confirmed its content. The manager confirmed that resident meetings take place on a regular basis and residents are encouraged to make their own decisions and choices. The fire logbook was examined and found to be generally in order. It was noted that the fire drills were not within timescale but this had recently been amended and the manager confirms will remain on track. It was pleasing to note that the residents are involved in fire training and drills and the manager has plans to make a video with residents regarding fire safety. It was confirmed that all statutory training had been undertaken including COSHH, first aid, fire training and food hygiene. Freeways Trust supplies each of their homes with set policies and procedures for staff and residents. There are copies of certain documents on the staff’s notice board such as ‘missing persons’; fire safety; and emergencies. At the last inspection the inspector noted a number of residents attended a policies group called ‘Our Project’. This is commended and ensures continued involvement in decision-making processes. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 22 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 2 25 3 26 3 27 3 28 3 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 3 3 3 2 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 3 3 X 3 X X 3 X Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 23 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 YA30 Regulation 23(2)(d) Requirement Timescale for action 10/09/06 2 YA9 3 YA9 4 YA9 5 YA24 6 YA24 Take action to improve standards of cleanliness in bedrooms and in all other areas of the home. Maintain good levels of cleanliness. 13(4)(b) Put in place a risk assessment to manage the risk of one resident refusing to get into a taxi or other vehicle. Add this to the care plan. 13(4)(b)(c) Any support necessary to minimise a risk must be detailed and adequately recorded in a risk assessment. Review and amend all risk assessments. 13(4)(b)(c) Put in place risk assessments to deal with severe episodes of incontinence as this challenges the service and affects the other residents in the home. 23(2)(b)(d) One bedroom is in need of redecoration and investigations into the damp patches. 13(4)(a)(b)(c) The TV in one bedroom must be ‘made safe’ and the risk of it falling onto a resident eliminated. DS0000026542.V290948.R01.S.doc 01/09/06 01/10/06 10/09/06 01/12/06 01/09/06 Morley House Version 5.1 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA23 YA24 Good Practice Recommendations Ensure that residents’ sign care plans and related reviews including risk assessments. Attend training provided by Bristol Social Services carried out by the Adult Protection Coordinator to ensure staff are up to date with current legislation and best practice. The tiles to be removed in one bedroom and the wardrobes removed and modernised. Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Morley House DS0000026542.V290948.R01.S.doc Version 5.1 Page 26 - 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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