Inspection on 03/01/07 for PIA 4 Milverton Terrace

This inspection was carried out on 3rd January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

PIA 4 Milverton Terrace 07/01/08

PIA 4 Milverton Terrace 01/02/06

PIA 4 Milverton Terrace 10/08/05

PIA 4 Milverton Terrace 10/02/05

PIA 4 Milverton Terrace 12/08/04

PIA 4 Milverton Terrace 11/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 PIA 4 Milverton Terrace 4 Milverton Terrace Leamington Spa Warwickshire CV32 5BA Lead Inspector Martin Brown Key Unannounced Inspection 3rd January 2007 1:00pm PIA 4 Milverton Terrace DS0000004224.V324583.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 PIA 4 Milverton Terrace DS0000004224.V324583.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. PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service PIA 4 Milverton Terrace Address 4 Milverton Terrace Leamington Spa Warwickshire CV32 5BA 01926 882831 02476 640146 dkelly@people-in-action.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) People in Action Deborah Charlotte Kelly Care Home 8 Category(ies) of Learning disability (8) registration, with number of places PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the extra bedroom is only to be used by a service user coming to live at the property for a contracted period of six months or less. Service users residing in this bedroom must not use any other bedroom in the property during their stay in the home. 1st February 2006 Date of last inspection Brief Description of the Service: Milverton Terrace is a registered care home providing short-term care with the aim of supporting people with learning disability wishing to live, with support, in their own home and wider community. The parent company, People in Action provide 24-hour care and support for service users living in the home. The home is a large converted house, close to the town centre of Leamington Spa. Shared accommodation consists of a lounge, dining room and kitchen. There is also a bathroom, toilet, laundry and office on the ground floor. There are two service user bedrooms on the ground floor, which are suitable for wheelchair users. Other service user bedrooms and the staff sleep in room, and a shower/toilet facility are located on the first floor. There is a garden to the rear of the property. There is limited access to the front of the property for car parking. Entrance to the home at the front is via a series of steps up to the front door. There is wheelchair access to the property however at the side of the building. Fees at the home range from £800 to £1600 per person per week, with the average being £1125. PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been made using evidence that has been accumulated by the Commission for Social Care Inspection. This includes information provided by the home, and a visit to the home. Questionnaires from residents, relatives or significant others were not requested on this occasion, but a number of relatives were contacted for their views during or following the inspection. The pre-inspection questionnaire was completed and returned by the manager. The inspection visit was unannounced, and took place on January 3rd 2007, between 1pm and 6pm. The manager was unable to be present during this inspection. A tour of the premises was made, relevant documentation was looked at, staff and residents were spoken with, and interactions between staff and residents observed. Three residents were ‘case tracked’, that is, their records and experience in the home were examined in detail. What the service does well: What has improved since the last inspection? What they could do better: The service should have a more pro-active role in assessing people entering and leaving the service The service sees itself as an assessment service; it needs to ensure that it, and the people using the service, are central to the assessment process. PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 Page 6 At present, it appears that whilst the care provided by the service is very good, decisions regarding the long-term futures of residents are rather divorced from the service, users of the service, and their relatives. There was little evidence seen in care plans or in discussion with staff or relatives of how the service was making the wishes and needs of service users a central part of any decision regarding their futures. Although very complimentary about the care at Milverton Terrace, some relatives spoken to expressed a feeling of powerlessness about the future of service users. Service user friendly ‘life story books’ written in the first person and with simple captions and photographs would be a useful tool in demonstrating individual strengths and needs, likes and dislikes and helping point to desirable future living options. There must be adequate stock control of all medication. 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. PIA 4 Milverton Terrace DS0000004224.V324583.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 PIA 4 Milverton Terrace DS0000004224.V324583.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users needs and aspirations are compromised by the home not having its own its own assessment tool and consequently having to place a heavy reliance on the assessments of outside agencies. EVIDENCE: Users of the service at 4 Milverton Terrace come here for a short term period, during which assessments are made by outside professionals, with input and involvement from the home, into suitable options for the future. A sample of three recent admissions to the home was looked at. These are done by outside professionals, rather than by the home itself. They give details of the individual’s needs and aspirations, but as they are completed by people outside the home, they do not indicate how individual needs may be affected by, or by met by, the environment of Milverton Terrace. The assessment of one person, who was an emergency placement, was written two years previous to his move to Milverton Terrace. Staff found that some of the information was not relevant to his current situation. Much of the assessment work in the home is on-going, with he home gathering information to support any future placement. Staff spoken to advised that they were not aware of the service having had accepted anyone whose needs it could not meet. PIA 4 Milverton Terrace DS0000004224.V324583.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): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents needs are reflected in their individual care plans, and that they are supported in making choices and taking risks as part of their individual development. Service users might be more confident that their long-term futures were being planned more with their own individual needs in mind if the service took a more pro-active and central role in the assessment and planning for individual futures. More detailed, service-user friendly care profiles, or ‘life story’ books, with details of experiences, likes and dislikes, might help with this. EVIDENCE: A sample of four individual care files were looked at. These showed good clear guidance, particularly where individuals needed a lot of prompts and support in respect of making choices and where staff needed guidance to ensure consistency in issues of personal care. PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 Page 10 Where people were at the home for more than six months, reviews of care plans were in evidence. Care plans showed how people were supported to make decisions, and contained, as well as care and behavioural guidelines as applicable, details of individual risks and how they were to be managed. Staff were able to demonstrate in discussion, a thorough knowledge of individual service users needs, and a consistent approach to meeting those needs. This was further demonstrated in staff interaction with service users, where individual needs were anticipated and supported. Staff frequently spoke of the service as an assessment service, but it was not clear how care plans and recording were contributing towards assessments and the future placements of individual service users. At present, care reviews appear to be something undertaken by outside agencies with informal input by the service. Relatives spoken to commented that, although invited to reviews, they are not always clear on what the plans are for their loved ones, and can feel a little excluded from the process. Relatives emphasised that they regarded this as a shortcoming of the system as a whole, rather than the home, which they generally felt was very good at keeping them informed about day-to-day issues. Relatives generally felt that individual service users would benefit if the home took a more central and pro-active role in the assessment process. One relative felt frustration at times not being clear what activities a service user had taken part in, and felt some sort of photographic record, or life story book, might be a useful document. PIA 4 Milverton Terrace DS0000004224.V324583.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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home benefit from a variety of activities, and a variety of nutritious food, attractively presented and eaten in a congenial atmosphere. EVIDENCE: Those using the service have a wide variety of needs and wishes, all catered for individually. One service user was absent on a regular hospital stay. Two more were attending individual day services for part of the inspection. One person returned from a work placement the late afternoon, another was happy to go out to the shops with a staff member. Three service users did not go out, but received individual attention from staff. Two current service users with high mobility needs have their own vehicles to help them get out and about. Other service users use the small van provided by the service, paying a contribution towards petrol use according to usage. PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 Page 12 One service user was looking forward to going out to a local pub later in the evening with a relative, another was looking forward to going out dancing, later in the evening, although she was unsure what this involved. It was apparent from discussion with staff, and from records, that families are regular and welcome visitors. Observation of staff interactions with service users showed them respecting individual rights, by knocking on people’s doors before entering, and trying to ascertain people’s wishes wherever possible. Staff were seen to be encouraging self-help skills and responsibilities, in, for example, encouraging individuals to make decisions about what activities to do. Menus showed a variety of wholesome foods. Meals are cooked on a group basis, with everyone sharing the main mealtime. Residents waited keenly, but patiently, for the main, evening meal. Individual preferences are catered for, with one person being encouraged to eat communally, but with recognition that eating alone was often a preference. Staff advised that, at present, there are no special diets as required by, for example, diabetes, but that one person requires a low sodium diet, which is catered for by avoiding processed foods and the addition of salt to cooking. One person has a ‘peg’ feed, owing to a reluctance to eat, but is encouraged to eat and drink by staff. People were seen to be supported by staff as necessary during the afternoon meal. PIA 4 Milverton Terrace DS0000004224.V324583.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): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health needs of service users continue to be met with the involvement of health specialists as needed. Recent shortcomings in medication administration and recording have been addressed by with increased training and improved procedures. Completely satisfactory medication administration and recording remains compromised by insufficient stock control of some medication. EVIDENCE: Individual care records demonstrate that the service continues to make appropriate use of health professionals to help manage and resolve health concerns regarding individual residents, with numerous examples of relevant specialists being involved in helping improve the quality of life for individuals by supporting the service in addressing health and behavioural issues. Staff were observed to be supporting service users in ways that maintained their dignity and respect, whilst ensuring that their physical and health needs were met. PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 Page 14 One service user uses a ‘peg’ feed as a supplement. All appropriate guidelines were seen to be in place, and relevant professionals involved in the care, with staff receiving the necessary training and support. There had been notifications from the service concerning a number of errors concerning the administration and recording of medication since the previous inspection, mostly occurring over the summer period. These have been addressed by additional training, guidance and improved procedures, and there have been no further notifications of errors since the summer. Medication records were clear, and those looked at appeared accurate, and tallied with medications issued from ‘blister’ packs. Some medication cannot be dispensed by blister pack. The amount of these received was recorded, but where there were ones still remaining from the previous month, these were not totalled, resulting in their not being a full and accurate record of the amount of this medication in stock. The team leader present acknowledged that without this accurate stock control, it could not be confirmed, with any degree of accuracy, that medication signed for had been administered, or if any shortfalls had occurred. PIA 4 Milverton Terrace DS0000004224.V324583.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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Users of the service can be confident that complaints are responded to and that they are protected against abuse. EVIDENCE: The complaints book was looked at. This recorded all complaints; where these indicated a need for confidentiality, the records of the process and the outcome were kept securely, and cross-referenced. These were not available, in the absence of the manager. Relatives spoken with said that they were happy with the care provided, and that the staff and management were very ‘approachable’. One relative commented that when there had been a few ‘niggles’ a word with staff had soon been able to sort this out. Staff spoken with showed a good awareness of abuse and what action to take in the event of abuse being suspected. An example of alleged abuse was discussed, which demonstrated staff aware of abuse and the issues surrounding abuse. Staff/service user interactions witnessed all demonstrated a positive and respectful approach to service users. Abuse policies are in place, staff receive abuse awareness training, and service users who do not have regular contact with relatives have access to advocates. PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from a spacious environment in which improvements have been made. There is still some work to be done to make all parts of the building satisfactory. EVIDENCE: The environment was clean and odour-free. The lounge and dining room are spacious and pleasantly decorated. A small room upstairs has been converted into a small lounge which, staff advised, can be used occasionally by people who want some time alone in a room other than their bedroom. Bedrooms are spacious and adapted to individual needs and wishes. They all now have new flooring. Two beds seen were without headboards, making them seem rather institutional. Bedroom doors are all plain white. Staff agreed that service users may benefit from having their names, a picture or similar on them. One door has an object of reference on it to help the occupant identify it. PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 Page 17 One bedroom had recently suffered damage to the door, which was awaiting repair. The damage had compromised its fire safety. Flood damage from an upstairs shower has been made good, and the shower doors more effectively sealed to prevent a re-occurrence. Some repainted has lessened the effect of wheelchair or similar damage on doors and skirting boards. Damaged work surfaces in the kitchen have been replaced. The skirting board near the side entrance/exit is rotted, an electrical device, suspected by staff to be a doorbell, next to an upstairs bedroom, had no cover, exposing wires. Staff agreed it needed covering or removing. The steps leading to the front door have cracks in their surface and some of this has crumbled. There is a handrail on one side only. There is a ramp entrance at the rear of the building. Some of the back garden has been lost, as, staff informed me, a large portion of this has been sold by the landlord. There is a lift, staff advised that this is now working, but is not used by anyone in the home. There are two bedrooms on the ground floor available for anyone with impaired mobility Toilets were clean, but two had empty paper towel dispensers, and one had no toilet rolls. Staff advised that one person tended to put the toilet rolls in that particular toilet down the toilet. They acknowledged that the service should be looking for a more positive solution to this problem. PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from a consistent, well-trained staff team, who are knowledgeable about their needs and how to meet them. EVIDENCE: Staff spoken to were positive about the service and about training. Over half the staff now have relevant National Vocational Qualifications. The pre inspection questionnaire returned by the manager showed mandatory and specialist training continuing to be ongoing. Staff were seen to work effectively as a team, supporting each other and anticipating needs when difficulties arose in supporting a service user. Staff showed, in discussion, a good knowledge of individual service users and their needs, and were seen to approach and support service users in a warm and positive manner at all times. PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 Page 19 In the absence of the manager, staff recruitment records were not accessible, but previous inspections, experience of other services run by this organisation, the pre-inspection questionnaire returned by the manager, and observation and discussion with individual staff gave no reason to suppose there were any concerns in this area. Relatives spoken to during and after the inspection were positive about the service, commenting that there were ‘always enough staff,’ that they were always easy to talk to, and that the home was staffed by a consistent and knowledgeable staff team. PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users and relatives are able to be reasonably confident that their views are reflected in the running of the home. What is less clear is how their views are reflected in respect of long-term living options. The home promotes the health, safety and welfare of service users. Safety remains potentially compromised by the condition of the front steps. EVIDENCE: The manager was not available during the inspection, but the home was run competently in her absence with team leaders taking individual responsibility for shifts and area management support being available if needed. Relatives were positive about the running of the home and the approachability and abilities of staff and management. PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 Page 21 There are monthly meetings for service users and observations and discussions with staff and service users demonstrated that the service works hard to ascertain service users’ views and to meet needs accordingly. Staff were observed checking out with service users as to what they wished to do, and explained how, where appropriate, they would try new activities and experiences with service users and gauge their reactions. Relatives spoken to were appreciative of the care, and stated that staff were open and receptive and kept them informed of care issues. However, relatives expressed concern that they were not always aware of the assessment process and of the future plans for their loved ones. They acknowledged that in some instances the home itself may not have all the information, but felt that as an assessment centre, the service itself should be more central to the assessment process and the permanent destinations of the people who use the service. The pre-inspection questionnaire returned by the manager indicated that fire and other health and safety checks take place as required. Regular checking of fridge and freezer temperatures now takes place. Staff spoken to showed a good awareness of fire safety and procedures. There is still only one hand rail on the front steps. There are cracks in these steps. Staff advised that they always escort service users when entering or leaving the building. The front door is always locked. There is a separate, ramped, entrance for those with high mobility needs. PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 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 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 2 x PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 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 YA20 Regulation 13(2) Requirement Timescale for action 10/02/07 2. 3. 4. 5. YA24 YA24 YA30 YA42 The registered provider that a must ensure that sufficient stock control is in place to confirm that all medications are administered and recorded accurately. 23 The rotten skirting board must be made good 23 The damaged bedroom door must be made good. 13(3) Toilets must be adequately stocked with necessary items to maintain hygiene. 13.4(a).23.2(b) The registered provider must ensure that the front steps can be used safely by all service users who do so. 10/03/07 10/02/07 10/02/07 10/03/07 PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 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 Refer to Standard YA2 YA6 Good Practice Recommendations It is strongly recommended that the home develops and uses its own assessment tool for people entering the service. It is strongly recommended that the home pursue a more pro-active approach to ensuring that decisions regarding long-term placements are based on individual needs and wishes, fully using assessments and information gleaned by the service. ‘Life story’ books or similar service user friendly documents would help make service users more central to decisions about their futures. It is recommended that headboards are provided for those beds currently without them. It is recommended that the service consider personalising people’s bedroom doors are with names or pictures. 3 4 5 YA6 YA26 YA26 PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 PIA 4 Milverton Terrace DS0000004224.V324583.R01.S.doc Version 5.2 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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