CARE HOMES FOR OLDER PEOPLE
Phoenix House 54 Andrews Lane Formby Liverpool Merseyside L37 2EW Lead Inspector
Mrs Trish Thomas Key Unannounced Inspection 21st April 2008 09:30 X10015.doc Version 1.40 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 Phoenix House DS0000064015.V361866.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 Older People. 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. Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Phoenix House Address 54 Andrews Lane Formby Liverpool Merseyside L37 2EW 01704 831866 01704 831866 phoenix_house@hotmail.co.uk 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) Total Care Homes Ltd Sandra Farrell Care Home 18 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (16), of places Sensory impairment (1) Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include 18 OP The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 9th July 2007 Date of last inspection Brief Description of the Service: Phoenix House is a care home for eighteen older people situated in a quiet residential street in Formby, close to a bus route and train station. The home is a converted Victorian villa with a car park at the front of the building and a garden at the back. There is a large communal lounge, a separate dining room, and bedrooms are situated on ground and upper floors. There is a passenger lift for use by residents who are accommodated on upper floors. The home has an assisted bath, and does not have a hoist. Phoenix House is staffed throughout the day and night, providing personal care, home cooked meals and a laundry service. All residents are registered with a G.P. of their choice and are supported to receive the services of district nurses and paramedical services, as needed. The registered provider of Phoenix House is Dr. Chris Farrar, Total Care Homes Limited, and the registered manager is Mrs. Sandra Farrell. An extension to the premises is nearing completion. The weekly charge in Phoenix House is £398.00 and not included in the fee are the costs of hairdressing and chiropody. Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means that people who use the service receive good quality outcomes. During this un announced inspection, we (the commission) spoke with the registered manager, Mrs. Sandra Farrell and the registered provider, Dr. Chris Farrar. We looked at records compiled in Phoenix House about health & safety and staffing. We read people’s care files and looked closely at the care plans of two people, to make sure there are good systems in place to meet each resident’s assessed needs. We spoke with residents, visitors and staff and made a tour of the premises. We read the Annual Quality Assurance Assessment, which had been filled out and returned to us before the visit. This is a self-assessment questionnaire, which gives us information about how the home is managed and any planned improvements to the service. Questionnaires, which were sent by us to Phoenix House for residents and staff to complete before the visit, had not been returned to us by the time of this report. When received, the comments will be recorded for future reference. We looked at the outcomes of an internal quality audit carried out recently by Dr. Farrar, which takes account of residents’ views about Phoenix House. What the service does well:
There are good systems for assessing people’s needs and giving them information before they move in to Phoenix House. This gives them the knowledge they need to make an informed decision as to whether Phoenix House will be a suitable home. Care plans are comprehensive and easy for staff to follow. Reviews have been carried out regularly to ensure that records of each person’s condition are up to date and they can be properly supported. Risks to each person’s health and safety are carried out and action taken to avoid accidents and injury. Medical interventions are clearly stated in care plans, and in this way information about each person’s health, is accessible to staff and health professionals. For residents’ protection there is a clear complaints procedure, which is given to them. For staff guidance safeguarding procedures and training are in place. In this way staff will be aware of the indicators of abuse and procedures they should follow in reporting suspected abuse of a resident to the relevant agencies. There have been no complaints or safeguarding referrals about Phoenix House since the last visit. Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
There are systems for managing residents’ prescribed medication, however it is recommended that handwritten alterations to medication administration records are signed by the writer, checked against pharmacy containers and signed by a colleague. In this way errors and risks to residents of receiving the wrong dose or medication, will be avoided. Regarding a requirement made from the last visit, to improve the meals provided to residents of Phoenix House. A number of residents said that they were satisfied with their meals, their comments varied from, “Not bad” to “Good”. Some residents remain dissatisfied with the meals on offer, saying they are, “Frozen, not fresh”, “Cooked in the microwave” and “Processed.” On the day of the visit, the midday and evening meals served to residents (fish in butter sauce and pancakes with mince), were processed. A recommendation is given that consultation with residents on meals is ongoing and in this way there will be a choice of fresh, processed and frozen foods daily, to meet the needs and preferences of everybody living in Phoenix House. Likewise regarding a requirement from the last visit to improve the range of activities and outings on offer, action has been taken to meet the requirement. Some residents were satisfied with their lifestyle in Phoenix House, others
Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 7 (including a visitor), said there is little to do and few outings for the people living there. A recommendation is given that consultation on activities be ongoing to ensure the social needs and preferences of all will be met. Further action is needed to ensure that residents’ diversity is promoted, and a recommendation is given that care plans be updated to record whether or not people would like a minister of their chosen faith to visit. This will ensure that everybody can follow their religious beliefs if that is their choice. Due to building work in progress, there was little outside space for residents to use safely during fine weather. It is recommended that an area be made safe for residents’ use until building work is complete and facilities are in line with the service user guide. 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. Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People have had their needs assessed before moving in to Phoenix House and they are given plenty of information about the service, to inform the decision as to whether this home will be a suitable place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 1 and 3. (Phoenix House does not provide intermediate care and will not be assessed against standard 6). Phoenix House has a service user guide and statement of purpose, which are given to people before they move in. In this way people have plenty of information about this home before they make a decision as to whether it will be suitable for them. The care file of the person who moved in to Phoenix House most recently, was read. Staff had carried out an assessment of the persons needs before they moved in, to ensure there were the facilities and skills in Phoenix House to meet those needs. The assessment covered a range of health and personal
Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 10 care needs, physical and social needs and the outcomes formed the basis of this person’s care plan. Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Each person’s health and personal care needs are set out in an individual care plan, which is regularly reviewed to identify any change in the person’s condition. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 7, 8,9 and 10. The care plans of two residents were tracked in detail and there were action plans in place to meet the outcomes of each person’s assessment. In this way staff have written guidance as to how to support the person and care is provided to the individual, in a consistent way. Care plans are reviewed regularly and the person’s opinions taken into consideration, for example during one review a resident asked to have meals served in her bedroom and this is now happening. Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 12 The care plans were easy to follow and there were records of medical interventions such as visits from the G.P., physiotherapist, speech therapist and district nurse and contact with paramedical services such as chiropodists and dentists. To help avoid the development of pressure sores and to assess the risk of falls or injury to the person, risk assessments had been carried out regarding pressure care and mobility. Residents and visitors who were spoken with were satisfied with the care and support provided to people in Phoenix House. A visitor said her relative is well looked after. A resident said she has lived in Phoenix House for many years and wouldn’t have stayed so long if she did not like it. There is a system in place for managing residents’ prescribed medication and written procedures for staff to follow. There was evidence in care files that if a person refuses to take their medication, this is recorded and reported to the G.P. for guidance. Storage of drugs and the medication administration records were satisfactory at the time of visit. It is recommended that handwritten additions to medication records, be signed by the writer, and checked against the pharmacy containers and signed as being correct by a colleague. In this way, errors will be avoided. Residents were spending time as they choose and there was a relaxed atmosphere in Phoenix House during the visit. One person said, “I like to spend time in my bedroom, I have all I need and no-one bothers me.” Another person said, “I love my bedroom, it’s very relaxing, I like to have a rest in the afternoon.” Residents said that staff and mainly polite and respectful. Residents said their clothes are returned to them in good condition after laundering. Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Although there is a relaxed atmosphere and people spend time as they choose and in comfort, the service does not cater for everybody’s preferences regarding leisure and meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 12,13,14,15. There is an activities programme in Phoenix House, there are board games, and books in evidence and some residents order a daily newspaper. However, feelings about leisure events in this home were mixed. Some residents said everything was going well, others said there is little to do and concern was expressed about the reduction in the size of the garden since the new building was started. A resident said, “There is nowhere suitable to sit outside at present.” Another said, “The days can be very long.” A resident said, “I have lived here for a long time and am perfectly content. I wouldn’t have stayed if I did not like it. I spend time in my bedroom and my visitors come regularly. Things are going well.” Given the mixed feelings expressed about activities, a recommendation is made that consultation with residents on activities and outings is continuous, to ensure that everybody’s needs in this will be addressed.
Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 14 There was no evidence in residents’ care files, which were seen, that they receive support for their religious beliefs from visiting ministers of their church. Further action is needed to ensure that residents’ diversity is promoted, and a recommendation is given that care plans be updated to record whether or not people would like a minister of their chosen faith to visit. This will ensure that everybody can follow their religious beliefs if that is their choice. There was evidence that residents’ preferences of daily routines, rising and retiring times and voting arrangements are recorded and catered for. Two visitors were spoken with. They said that they had no major concerns although they felt that there could be more activities arranged for residents during the daytime. A resident said, “I have not been out for ages. When I do go a relative takes me, there are very few outings here. It is difficult seeing the same four walls from day to day.” There was mixed comment regarding meals. Three residents said the meals were, “Not bad – good.” It is on record in a resident’s monthly care review that she considers the food to be, “Good.” Other residents were not satisfied. They said, “The food is all frozen, we seldom see a fresh vegetable.” “Food is cooked in the microwave, nothing is home made.” “There is something not right about the food here.” “The stew is awful, one person left it last time, it was tasteless.” On the day of the visit, residents were served a main menu of fish in butter sauce, mixed vegetables and mash, with cheesecake for dessert. There were alternatives on offer for residents who didn’t want the main menu. For the evening meal the main choice was frozen pancakes with mince filling (or sandwiches) and birthday cake. Most of the food served that day (ie. fish and pancakes) was processed. There was little food in the freezer and the cook said shopping is done as often as needed. There was bread and milk in store, cereals and a choice of drinks. There were no fresh vegetables or fruit in evidence. Residents said they are served roast dinners at weekends, with fresh vegetables and roast potatoes from a packet. The meal for the following day was to be corned beef hash, apple pie and custard. Given the mixed opinions stated about the quality of food, a recommendation is given that consultation with residents about this be ongoing. In this way there will be a choice of fresh, frozen and processed food on offer daily, to meet the needs and preferences of all those in residence. Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents are protected through the procedures and training in Phoenix House and their complaints are taken seriously. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 16 and 18. In the Annual Quality Assurance Assessment it is stated, “We receive many compliments from visitors and anything that residents are unhappy about are usually resolved and rectified.” “In-house training on safeguarding was provided by way of questions and answers and providing literature for staff to read. External training in this would be beneficial.” To ensure that residents’ complaints will be dealt with, Phoenix House has a complaints procedure, which is given to residents and their representatives with the service user guide and statement of purpose. A record of all complaints is kept in the home. There have been no complaints or safeguarding referrals about Phoenix House since the key inspection 2007. For staff guidance there are safeguarding and “whistle-blowing” procedures and staff have received relevant training. A member of staff who was spoken with was aware of the procedures to be followed in alerting relevant agencies if abuse was to be suspected in Phoenix House.
Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 16 Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. The building is in generally good condition, until building work is completed, outside space for residents is limited. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 19, 26. The building was clean and in reasonably good decorative order. Given that a large extension has been built, there was little evidence of the dust associated with building work, in the home. Dr. Farrar said the deadline for completion of the extension is July 08. The extension was seen from the outside and Dr. Farrar said it will improve facilities for residents of Phoenix House. The hall/stair carpet in the main building is very worn and shabby. Dr. Farrar said this is to be replaced when building work is done. The dining room is pleasant with enough tables and seating for the people who live there. The
Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 18 tables had been laid for the meals with great care. The lounge is in good condition with comfortable seating for residents. Bedrooms, which were visited, were clean and highly personalised. A resident said, “I love my bedroom and have it the way I want it.” She explained her relatives who were in the photographs she had around the room. The bedding was freshly laundered and the room contained occasional furnishings for her comfort and convenience. A resident said the portable ramp used at the front door is not suitable for her wheelchair and it is difficult to negotiate if she wants to go out. Dr. Farrar said that the extension, when completed, is to have level access for people in wheelchairs. There are assisted bathing/showering facilities in Phoenix House, raised toilet seats and grab rails to help residents who have poor mobility. Phoenix House does not have a hoist and Dr. Farrar said a hoist is not needed for people who currently live in Phoenix House as they are weight bearing. There is a passenger lift, which was in working order at the time of the visit and had been serviced. Some upper bedrooms do not have level access to the lift and are therefore suitable only for people who can negotiate steps. Domestic staff are employed and there are procedures for infection control and control of substances hazardous to health. The kitchen was very clean in all areas and was well organised, as was the laundry, despite alterations in progress to move the boilers. Residents said they found the home to be clean and comfortable and they also remarked on the garden. The extension has eaten into the garden and as the building work was not complete, there was a limited amount of outside space for residents to use safely at the time of the visit. A recommendation is given that an area of the garden be made safe for residents’ use, until such time as the extension is completed and the garden returned to its’ former condition. The front of the building was well looked after, and the pots had been planted with fresh flowers. Dr. Farrar confirmed that the loose tile on the roof has been fixed since the last visit. Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents are protected through the recruitment procedures and training in Phoenix House. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 27,28,29,30. During the visit there were two care assistants, the manager and one cook and one domestic for sixteen residents. The rosters gave a true account of staff on duty. Phoenix House was fully staffed at the time of this visit. In the Annual Quality Assurance Assessment it is stated, “Two staff have successfully completed NVQ Level 4. A training matrix has been designed for new staff in the extension with emphasis on dementia.” There is a programme of mandatory and NVQ training, which is ongoing to meet the demands of a fairly high turnover of staff and to update long-term employed staff. Some training is in need of refreshing, such as that for supporting people who have dementia. Dr. Farrar said that he has identified the “Yesterday, Today and Tomorrow” training in dementia as the most relevant to Phoenix House, and he has obtained the paperwork to provide this training for staff.
Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 20 We discussed training and procedures with a member of care staff. She knew about accident reporting and safeguarding procedures and has had food hygiene and first aid training. She said recent activities for residents have included videos and wine, bingo, skittles, cards. Three staff files were seen and these were in order containing proof of identity, references, CRB checks and POVA. There is a satisfactory recruitment procedure, evidence of which was read in the staff files. In this way residents will be protected through employing staff who are of good character. Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents are protected through the management systems in Phoenix House This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standards 31,33,35,38. The manager, Mrs. Sandra Farrell, has worked in Phoenix House for many years and has recently completed NVQ 4 in management. Mrs. Farrell has provided continuity to residents over the years and a resident said, “Sandra attends to everything, I would go to her for help.” An administrator is employed to undertake clerical duties and in the Annual Quality Assurance Assessment it is stated, “We have installed bespoke computerised applications
Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 22 for all areas in the office.” In this way confidentiality and ease access of information will be provided in Phoenix House. There are systems in place for obtaining residents’ views on the service provided in Phoenix House. A recent internal quality assurance audit for 2008 resulted in general satisfaction with the service from the 25 questions asked of residents and their families. Dr. Farrar said the outcomes are analysed and remedial action taken if necessary. Dr. Farrar confirmed that the home has no involvement in residents’ financial affairs. A resident said “I manage my own money, I have no concerns in that way.” Another said, “My (relative) deals with everything, I don’t get involved.” Another resident said, “I have no concerns about money, the staff do not become involved in my private affairs.” Some residents were unclear about the increase in their fees for the coming year. This was discussed with Dr. Farrar who said residents are informed of the new fees in writing and he will respond to any queries. This will ensure that residents know what the charges will be for this service, and avoid any misunderstandings or anxiety amongst them. We looked at health & safety documentation. Safety checks and certificates were in good order and up to date. Fire checks had been carried out regularly and risk assessments for fire safety, are in place. We discussed accident reports with Dr. Farrar who said that the equipment, which had caused an injury of bruising to a resident, (and all such similar equipment), has now been removed from the home to avoid further accidents. Phoenix House DS0000064015.V361866.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations Handwritten alterations to medication administration records are to be signed by the writer, and checked against pharmacy containers and signed by a colleague. In this way errors and risks to residents from receiving the wrong dose or medication, will be avoided. To ensure that residents’ diversity is promoted, it is recommended that care plans be updated to record whether or not people would like a minister of their chosen faith to visit. This will ensure that everybody can follow their religious beliefs if that is their choice. To ensure that the lifestyle in Phoenix House is meeting the needs of all residents, it is advised that consultation on activities with them, is ongoing. To ensure that the content and quality of meals is to residents’ satisfaction, it is advised that consultation with on this is ongoing.
DS0000064015.V361866.R01.S.doc Version 5.2 Page 25 2. OP12 3. OP12 4. OP15 Phoenix House 5. OP19 To ensure that the grounds are suitable for residents, it is advised that an area of the garden be made safe for residents’ use until building work is complete. Phoenix House DS0000064015.V361866.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG 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
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