Inspection on 01/05/07 for Norfolk Road (28)

This inspection was carried out on 1st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Norfolk Road (28) 25/04/08

Norfolk Road (28) 22/11/06

Norfolk Road (28) 07/03/06

Norfolk Road (28) 19/05/05

Norfolk Road (28) 11/12/04

Norfolk Road (28) 26/05/04

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 Norfolk Road (28) 28 Norfolk Road Harrogate North Yorkshire HG2 8DA Lead Inspector David White Key Unannounced Inspection 1st May 2007 09:30 Norfolk Road (28) DS0000007901.V334139.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 Norfolk Road (28) DS0000007901.V334139.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. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norfolk Road (28) Address 28 Norfolk Road Harrogate North Yorkshire HG2 8DA 01423 871288 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) norfolkroad@st-annes.org.uk St Anne’s Community Services vacant post Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2006 Brief Description of the Service: 28 Norfolk Road is a care home registered by St. Annes Community Services to provide personal care and accommodation for up to four adults with learning disabilities. The home consists of a semi-detached two-storey town house with garden areas to the front and rear including an enclosed area with hard standing for parking. The home is situated on a quiet road approximately one mile from the centre of Harrogate. Local community amenities and facilities, including shops, churches and pubs are within walking distance. Each of the four bedrooms is for single accommodation, none of which has en-suite facilities. These are all on the first floor and are accessed by a staircase. Current information about services provided at 28 Norfolk Rd in the form of a statement of purpose, service user guide and the most recent inspection report published by the Commission for Social Care Inspection are available by contacting the home. Information provided by the manager on 13th March 2007 indicated that the current weekly fee for the home is £305.40. Additional costs include toiletries, hairdressing, newspapers, activities and holidays. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • Reviewing information that has been received about the home since the last inspection. Information provided by the previous manager on a pre-inspection questionnaire. A comment card returned by a GP. This report follows an unannounced site visit undertaken on the 1st May 2007. This visit was carried out by one Regulation Inspector and took 6.5 hours with 4 hours preparation time. Time was spent talking to three residents; three care staff and the manager. Some residents have communication difficulties so photo surveys were used to gather information from residents through the use of pictures. Records relating to residents, staff and the management activities of the home were inspected. During the visit care practices were observed, where appropriate, and time was also spent watching the general activity in the home. This helped in gaining an insight into what life is like for residents living in the home. The manager was available for some of the inspection and the findings were discussed with him at the end of the site visit. What the service does well: Residents are encouraged as much as possible to make their own choices and this gives them control over their lives. The home is good at using different ways of communicating in order to provide residents with the information they need to be able to make their own decisions about their daily routines. Residents enjoy the range of activities that are on offer and are able to pursue their past and present leisure and social interests. Residents are involved in the planning of their meals and this helps to make sure that they receive a meal to suit their personal tastes. The atmosphere in the home is relaxed and welcoming and this enables residents to feel comfortable and safe. The staff team are committed to providing good standards of care for residents, so residents can feel confident that their needs will be met. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 6 House meetings are held in which residents meet up with staff to discuss various things about the home. This enables residents to be involved in decision-making about how the home is run. 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. The summary of this inspection report can be made available in other formats on request. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Proper pre-admission procedures are in place so that prospective residents can feel confident that their needs will be met by the home. EVIDENCE: The home has a pre-admission policy that outlines the procedures to be followed when people are considering moving into the home. There have been no admissions since the previous inspection visit, however, proper preadmission procedures have been followed in the past to make sure that only suitable people are admitted to the home. Information about the person’s care needs is collected from all available sources such as the placing authority to support the home in their decision making about whether they have the skills and resources to meet the person’s needs. All prospective residents are invited to visit the home and have a trial period before a decision is made about whether they move into the home on a permanent basis. Each resident has a licence agreement explaining the terms and conditions of their stay at the home. The records show that the residents and/or their representatives have signed the agreement. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents are encouraged to make choices about how they live their lives and this is supported through improved care planning documentation that takes into account any risks to residents in promoting their independence. EVIDENCE: Each resident has a person centred plan which places emphasis on how each resident prefers to be supported in meeting his or her aims and objectives. This takes into account personal choices about how residents choose their daily routines and includes information such as the people who are most important to them in their lives, their hobbies and interests and food likes and dislikes. Since the previous inspection visit a lot of work has been undertaken to improve the quality of the care planning documentation. The care plans are in simple language and are easy to follow and some of the information in the care Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 10 records is in picture format for residents with communication difficulties to encourage their involvement in the planning of their own care. Care plan reviews are now taking place on a regular basis with the involvement of the resident, their relatives and relevant others who are involved in their care. The reviews focus on the strengths of the individual and their future aims and goals. Outcomes from the reviews are also in picture format so that residents with communication difficulties are aware of what has been discussed and agreed within the meetings. Residents said that they are encouraged to be independent and to make their own decisions and this could be observed at the time of the site visit. A range of individual risk assessments is in place to promote residents’ independence and safety. The assessments include information about why decisions have been made where residents could be restricted in what they can do and these are agreed with the resident or their representative. Risk assessments are now reviewed on a more regular basis to make sure that any changing needs are identified and acted on. Daily records reflect how choices and decisions are made and these are up to date and accurately reflect the cares that are being given. The home has a key worker system so that residents receive support on an individual basis and residents said that they meet with their key worker to discuss their care. The home has handover periods so that information about residents is passed on between shift changes and there is a communication book to keep staff informed about any changes to care. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents enjoy a range of activities to suit their personal needs and are involved in the local community. EVIDENCE: The home is committed to promoting residents to be independent and to pursue their hobbies and interests. One resident has always liked football and goes to the watch his local football team with his key worker. Others enjoy activities such as attending the gym, bowling, swimming and visiting the pub. The care records show that in a recent care plan review one resident said that they would like to have an opportunity to do some paid work and actions have been taken to enable the resident to work towards this goal. Each resident is given the opportunity to go on holiday and the house meeting records show how residents are involved in the planning of all the activities. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 12 Help with communication skills is given to residents with communication problems. All the staff receive Makaton training so are able to communicate with residents using sign language. One resident who has communication difficulties can become anxious about their daily routines. In order to reduce this stress, the resident’s daily routine is displayed in photographs so that they know what they are doing on that particular day and when. Residents can see family and friends whenever they want. The care records show that relatives are kept informed about residents’ wellbeing and are involved in the planning of their care. Residents said that they like the meals on offer at the home. Menus are planned in advance with residents and alternative meals are available if a resident does not like what is on offer on a particular day. Specialist diets are catered for as in the case of one resident and consideration is given to healthy eating options. One resident is trying to lose some weight to improve their health and the care records show that the resident has been referred to a nutritionist for specialist support with this. Staff and residents could be seen eating their meals together in a relaxed unhurried atmosphere. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The personal and healthcare needs of residents are met. EVIDENCE: Each resident’s personal plan describes how support is to be given. Residents said that support is provided in private and in the way the resident wishes. A General Practitioner (GP) comment card stated that residents could always be seen in private when attending to their health needs. Residents all have a GP and have access to dental and chiropody services. Referrals are made to specialist services as and when required and staff support residents in attending appointments. There have been improvements in the recording of health care information in the care records and a healthcare checklist has been introduced. The records include more detailed information about why the residents are attending appointments and the outcomes from these. This helps in making sure that everyone is aware of the residents’ Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 14 health needs and how these are to be met. The introduction of a healthcare checklist that provides up to date information about when residents have attended appointments or need to do so further supports this. A GP made comments that the home communicates well with them in making sure that residents’ health needs are met. None of the current residents are able to administer their own medication. Proper procedures are in place for the receipt and disposal of medications. The home is using a system that requires staff to hand write all the details of medication onto the medication administration sheet. Staff are guided with this by information from a medication record card which provides details of each resident’s current prescribed medication. However, in one case the information on the medication record card had not been updated to reflect a change in the dosage of one particular type of medication and so did not correspond with the information on a resident’s medication administration record. Whilst a check of the records against the medication supplies confirmed that the correct dose of medication is being given, the inaccuracy of the information in the medication record card could have led to potential risks to the resident from not having the correct dosage of medication. This matter was brought to the attention of the manager and was dealt with immediately. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents’ concerns are dealt with properly and some measures have been put in place to improve the likelihood of appropriate action being taken in response to abuse so safeguarding residents from possible harm. EVIDENCE: The home has a complaints procedure that details how someone can make a complaint and the actions that would follow on from this. The complaints records show that the home has received two informal complaints since the last inspection visit and these had been dealt with satisfactorily. Residents know who they would need to speak to if they wish to raise concerns and staff said they would be able to be aware of concerns through observations of resident behaviour for those residents who may have difficulty in communicating. At the previous inspection visit there were concerns that the home had not followed adult protection procedures in responding to suspected abuse. There have been no further allegations or incidents of abuse since that visit so it is not possible to determine whether appropriate actions would be taken in future. However all the staff team have since received updated safeguarding adults training and staff said they now feel “more confident” in being able to Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 16 recognise abuse and in knowing what to do in response to allegations or incidents of abuse. Some residents display challenging behaviour and individual risk assessments are carried out to identify any risks from the behaviour and measures to be taken to reduce risks. Staff have had some training in promoting positive nonchallenging behaviour and this includes learning techniques that can be used to calm down situations. Some environmental restraints have been used in the past for one resident and a risk assessment is in place describing why these measures had been taken and the control measures that needed to be put in place if there is a re-occurrence of the behaviour. This is reviewed regularly to address any changing needs of the resident. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home provides a clean, comfortable and safe environment for residents. EVIDENCE: The home has two floors with bedroom accommodation all on the first floor. There are no lifts in the home and there is no ramped access to and from the premises so the home would not be suitable for people with mobility problems. Each resident has their own bedroom that is personalised and there are bathroom and toilet facilities that are easily accessible to residents on both floors. Aids and adaptations are appropriate in meeting the residents’ needs. The home is clean and tidy and residents said that they like living in the home. However it was observed that most of the décor is in need of updating to improve the standard of the living environment for residents. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 18 There are separate laundry facilities where staff attend to residents’ personal clothing and bedding and procedures are followed to reduce any risk of infection. Hot water temperatures are regularly monitored and any problems are referred to the maintenance team. A random check of the hot water temperatures was found to be satisfactory. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Improvements in staff training and the support staff receive in doing their jobs helps in making sure that residents are getting the care they require to meet their needs. EVIDENCE: The duty rotas show that there are at least two staff members on duty at all times through the day. On a night one member of staff sleeps on the premises and there is an on-call system if extra support needs to be accessed. Staffing rotas are flexible and are planned around residents’ needs. Residents said that they are always able to access staff if they needed any support. The staff file of the most recently employed member of staff shows that proper recruitment procedures are followed with all the necessary checks in place prior to new staff starting work at the home so safeguarding residents from potential harm. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 20 Staff undertake a range of training and this starts at the point of induction for all new staff. Since the previous inspection visit all the staff have undertaken adult protection training updates and all but two staff have had an emergency first aid update. These two staff are awaiting a place on the next planned course. The manager has obtained training records on each member of staff from the head office database so that he can plan training and is aware when staff are in need of updates. Training is provided that is specific to the needs of the resident group, however, the care records show that some residents also have mental health problems as well as a learning disability and it is recommended that staff have some mental health training to develop their skills and knowledge in this area in being able to meet all residents’ needs. Most of the staff have either completed or are doing a National Vocational Qualification (NVQ). Some staff who are doing the course said that there have been some delays in having their work verified to make sure it is up to the required standard and this matter is being addressed by the organisation. Staff meetings are regularly held and the records from these are available. A meeting has been held recently and staff found this to be “useful” in enabling them to voice their views and opinions about the home. A formal supervision system is now in place so that staff are supported in their job roles and any staffing issues can be addressed. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Recent management changes have improved the way the home is being run although better management arrangements would improve the consistency of care and services for residents. Residents are involved in the decision making in the home and overall their health and safety is protected although two matters need addressing to promote this. EVIDENCE: At the previous inspection visit there were concerns that the home was not being managed properly, mainly because the manager was spending little time at the home due to other work commitments. Since then the manager of the home at that time has left to manage another St Anne’s Community Services Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 22 home. It is now some time since the home has had a registered manager and this issue needs addressing to promote consistency in the home. An acting manager has been appointed on a temporary basis to run the home until a decision is made about the future management of the home. The acting manager has worked in the capacity of a deputy manager in one of the other organisation’s homes and has only been in post for a short time. He has a lot of experience of working with the resident group but has no management qualifications. Residents and staff both commented that the acting manager has had a positive impact on the home. People particularly like his “open approach” that encourages staff and residents to have their say in the running of the home. Staff said “it is good to have the manager around, just so that he is there if you need him and he listens and takes actions when needed”. The duty rotas show that the manager is spending most of his time based at the home. There are systems in place to find out the views of people about the running of the home. House meetings are held and records are kept and show how residents have been involved in decision-making. Relatives are invited to attend care plan reviews and their views are sought about the care and services on offer. The service manager for the organisation carries out audits of the home to monitor their performance. Staff meetings are held more regularly to enable staff to voice their views and opinions and staff are receiving supervision to support them in meeting residents’ needs. Overall health and safety practices help to maintain a safe environment. Fire safety is well maintained through fire safety checks and regular staff training. The home has carried out a fire risk assessment of the premises, however this is very basic and does not identify any environmental factors that could trigger a fire or any control measures that need to be put in place to reduce fire risk. A recommendation made from the most recent environmental health authority inspection visit has been acted on. A number of health and safety certificates are up to date, however there is no record that the electrical wiring systems in the home have been checked and this needs to be done so that any risks to the safety of the residents can be identified and any necessary actions taken. Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 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 2 2 3 X X 2 X Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 All medication details including administration instructions must be kept up to date and accurately reflect the medication being prescribed for each resident to make sure that residents are receiving the correct dosage of medication. All staff must receive updates of emergency first aid training so that they have the skills and knowledge to be able to respond appropriate to any immediate health needs, where appropriate. (This requirement remains outstanding from a previous report). The registered provider must submit an application for a registered manager to be processed. (This requirement remains outstanding from previous reports). Timescale for action 01/06/07 2. YA35 13 (4) 01/08/07 3. YA38 8 (1) 9 01/08/07 Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 25 4. YA42 23 (2) (b) A more detailed fire risk 01/07/07 assessment of the home must be undertaken in order to make sure that fire risks within the environment are identified and control measures are in place in order to reduce fire safety risks to residents. 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 YA24 Good Practice Recommendations Arrangements should be put in place to update the décor in the home in order to improve the standard of the living environment for residents. Staff should receive mental health training in order to develop their skills and knowledge in meeting the needs of those residents with mental health problems as well as a learning disability. 2. YA35 Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Norfolk Road (28) DS0000007901.V334139.R01.S.doc Version 5.2 Page 27 - 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!