Inspection on 13/10/06 for Poulton House

This inspection was carried out on 13th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 but made no statutory requirements on the home.

Other inspections for this house

Poulton House 15/07/08

Poulton House 20/03/06

Poulton House 22/11/05

Poulton House 07/02/05

Poulton House 25/08/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Poulton House Winterhey Avenue Wallasey Wirral CH44 4DX Lead Inspector Lesley Owen Key Unannounced Inspection 13th October 2006 11:30 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 Poulton House DS0000035570.V305027.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. Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Poulton House Address Winterhey Avenue Wallasey Wirral CH44 4DX 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) 0151 639 8844 Metropolitan Borough of Wirral Mrs Barbara Jean Norris Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Two (2) beds to accommodate persons under 65 years of age in an overall total of 38 (OP) 20th March 2006 Date of last inspection Brief Description of the Service: Poulton House is a large, two storey establishment set in well-maintained gardens. The home is registered with the CSCI to provide care and accommodation for 38 service users within the category of old age. Service users’ bedroom accommodation is single occupancy with bathroom facilities being shared. The large dining room is bright and pleasant in appearance; there are six lounges of a smaller size and all are comfortably furnished and well decorated. An area of the foyer is used as an additional communal sitting area. A separate room for visitors is also provided. Service users are currently admitted to the home on a short-term respite basis or for rehabilitation and assessment from hospital. There was one long stay service user although it is envisaged that the home will not admit further service users for long term care. In relation to the rehabilitation beds these are joint funded by Social Services and the local Primary Care Trust. A multi-professional team, including a physiotherapist, dietician, occupational therapist and social workers, work closely with members of the care team to assist in the assessment of service users and in providing support during their stay in the home. Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit began at 11.30am and took place over seven and a half hours, the registered manager and deputy manager were on duty at the start of the inspection. Both service users and staff were spoken to during the inspection. All relevant documents for service users and staff were reviewed. A tour of the building was made and a sample of maintenance records were seen. In addition the manager completed a pre-inspection questionnaire which provided the inspector with information and a survey forms were left at the home for residents to complete if they wished. What the service does well: What has improved since the last inspection? At the last inspection two recommendations were made about the procedures for giving medication which were to provide a specimen list of signatures of those staff responsible for giving medication and to introduce a new medication administration sheet at the beginning of every month to record when medication has been given. Both these recommendations have been put into practice. Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 6 Training for staff continues to be promoted and over 50 of care staff have now achieved A National Vocational Qualification. 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. Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 7 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 Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Prior to new service users being admitted to the home an assessment of their needs had been undertaken. EVIDENCE: The home has a Statement of Purpose and a service user guide which is available in each bedroom and provides service users with information about the service and facilities provided. The manager should ensure that this is reviewed at periodic intervals to ensure the information provided is up to date. All prospective service users are assessed prior to admission to the unit, the assessments are undertaken if a person is in hospital by a hospital social worker or a health professional. If the person is at home their GP would contact a social worker to undertake the assessment and if the someone wants to access the respite facilities an assessment would be arranged by contacting the local social services office, one stop shop or the manager at Poulton House. Emergency admissions can be made to the unit and if this were to happen all the criteria set out in Standards 2-4 of the National Minimum Standards would Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 9 be implemented. At present it is not usual practice for a representative of the home to visit and independently assess the prospective service prior to admission to the home. Due to the nature of the service provided at Poulton House it is not possible for all service users to visit the home prior to admission, as many come to the home directly from hospital. The care records of three people living at the home at the time of the inspection were examined and included people admitted for both respite care or for rehabilitation and assessment. Each record examined contained evidence that an assessment had been undertaken prior to admission. When a service user is admitted to the home this assessment document is then used to develop a care plan. When service users are admitted for rehabilitation and assessment a multidisciplinary team which includes physiotherapists, dietician, occupational therapist and social workers, work closely with members of the care team to assist in the assessment of service users self care abilities, in addition to providing support during their stay in the home. The home provides specialist facilities and equipment including a fully fitted rehabilitation kitchen and these are accessed where necessary during the service users stay. Service users admitted for rehabilitation and assessment stay on average three to four weeks, those placed for respite vary from a few days to two weeks depending on circumstances. The home has one long stay resident. Currently there are no charges for people placed for rehabilitation and assessment, the fee for respite care is £63.25 and for permanent residents £96.78. Additional charges are made for hairdressing, chiropody and newspapers. Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Care Planning continues to be developed in the home to ensure the needs of service users are met. Medication practices are within a safe framework and arrangements are put in place to ensure that service users healthcare needs are met EVIDENCE: During the inspection the inspector was able to view the care records of three people which included one person who had received respite care at the home and two people placed for rehabilitation and assessment. Care plans were in place in the files seen to meet the differing needs of service users placed. Records viewed included, assessment documentation, contract, self care report and risk assessments in relation to load management, falls and any other identified risks. Care plans had been drawn up by the allocated key worker with the service user when they were admitted to the home. In addition for service users placed for rehabilitation and assessment a physiotherapist also assesses the service user and devises an exercise programme which the care staff carry out with service users as directed and an occupational therapy assessment is undertaken. Records are maintained of key events and Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 11 assistance/support given with personal care is recorded separately. It is recommended that consideration be given to developing a single record where all issues affecting the service user including assistance and support given as part of the care plan are recorded. The plans of care for those service users placed for rehabilitation and assessment are reviewed at weekly multi disciplinary meetings held at the home to assess progress and to ensure appropriate care is being provided and needs met. All service users placed except for one long stay resident return to their own home or to other identified provision on leaving the Unit. It was evidenced through discussion, observation and individual diary sheets that service users health care needs are met. Staff at the home promote and maintain service users health care needs and arrangements are made for appropriate health care provision. Where required the district nursing team conduct pressure risk assessments and any equipment required is provided. The dietician who is part of the multi-disciplinary team, reviews service user’s dietary needs on admission. The home has appropriate policies and procedures in place for the management of medication. Service users are encouraged to self-medicate and risk assessments are completed prior to this which are monitored at weekly intervals. Service users have a lockable facility in their bedrooms to facilitate the safe storage of medication. All staff who are responsible for the administration of medication have undertaken external medication training which incorporates assessment of competence. Discussion with the manager and a senior carer on duty indicated that the staff responsible for dealing with medication were fully conversant with the systems in operation in the home. Medication Administration Record (MAR) sheets were examined and found to be satisfactory. A sample of medications were crossed checked with records maintained and found to balance. At the time of the inspection no controlled drugs were being administered in the home. As recommended at the time of the last inspection a list of specimen signatures of staff who administer medication was in place and each month a new MAR sheet to record when medication has been administered had been introduced. The home provides appropriate secure facilities for the storage of medication, including medication that requires refrigeration. Records of fridge temperatures are maintained. Arrangements are in place for the disposal of medication. The homes policies and procedures expect that all service users will be treated with respect. During the course of the inspection staff were observed speaking politely to residents and to support residents personal care needs in private. Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 12 Comments made by service users during individual discussion confirmed their satisfaction with the care and support received and spoke positively of the care they received. Poulton House DS0000035570.V305027.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. The daily routines in the home were flexible so residents were able to exercise choice, and have some control over their lifestyle. Meal times are relaxed and the food provided takes into account service users individual preferences and any special dietary needs Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 14 EVIDENCE: The daily routines in the home were observed to be as flexible as possible, and service users were encouraged to exercise choice and control over their lives. This was also confirmed both during discussion with the manager, staff and service users. Service users were observed spending time in their bedrooms, in the lounge areas or going out where possible either on their own or for home assessment visits with staff. The only routines in the home were the times when individual exercise programmes or assessments take place and these are negotiated with service users. Throughout the day staff spoke to service users in a respectful manner and knocked at bedroom doors before entering and good relationships were observed to have been developed between staff and service users The home does not employ an activities organiser and the staff group as a whole are responsible for activities in the home. Service users are encouraged to maintain any social activities or interests they have during their stay at the home. A programme of activities in displayed on the notice board on the ground floor corridor and one service user told the inspector about how they enjoyed the outside entertainer that had been provided at the home. Service users are free to join in activities or not as they wish. The home has an open visiting policy and welcomes visitors at any reasonable time. Service users are encouraged to maintain contacts with the local community and family and friends are encouraged to visit the home. During the course of the inspection several people were observed visiting service users in the home. The inspector was able to speak to the relative of one service user who regularly has respite care at the and they were happy with the service provided. Service users can meet with their visitors in the privacy of their own bedroom or in one of the communal areas or quiet rooms. The home has one large dining room which is decorated and furnished to a high standard and the individual dining tables were well presented with suitable crockery and cutlery. Facilities are provided for service users after risk assessment to prepare their own tea and snacks as part of their rehabilitation programme. Records are kept of individual service users likes and dislikes, individual preferences and dietary needs. Discreet observation of both lunch and tea confirmed that meals were relaxed and unhurried. Comments made by service users were complimentary about the food provided. Poulton House DS0000035570.V305027.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome is good. This judgement has been made using evidence available including a site visit to the service. The home has the appropriate policies and procedures in place to protect service users rights and ensure their safety EVIDENCE: A complaints procedure was in place and service users spoken to and survey forms returned confirmed that service users were aware of who to complain to. Information regarding how to make a complaint was available in the service user guide and a copy of this was available in each of the bedrooms. Any complaints would be recorded in the complaints log. No complaints have been received by the home or CSCI since the last inspection. Two comment/suggestion books are kept in the home and service users and their relatives are encouraged to make their views known. Examination of the comment books and comments made by both service users and visitors indicated that they were happy with the service provided. Comments made included “ staff including night staff are kind and cheerfully caring”, “I have felt a great benefit since I came to Poulton House” and “food excellent” were a few of the comments made. Staff within the home have access to Wirral Social Services adult protection procedures. All new staff during induction receive information and guidance about the protection of vulnerable adults and training in this area is provided on an on going basis. During discussion staff confirmed that they had received training in this area and confirmation was provided in the information Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 16 submitted prior to the inspection that all care staff have attended training in the protection of vulnerable adults. The home has a policy and procedure in relation to the management of service users money and valuables. At the time of the inspection the home was only providing assistance to one service user with their money. Where any assistance is provided or monies spent on a service user’s behalf receipts are obtained. Any monies held on behalf of service users are checked weekly by staff and random checks are undertaken by the Responsible Individual. Poulton House DS0000035570.V305027.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25 and 26 The quality in this outcome area is good. This judgement has been made using evidence available including a site visit to the home. Poulton House provides service users with a safe, comfortable and homely environment and where the standard of hygiene maintained is good. EVIDENCE: The home is a purpose built building which has been adapted over the years to meet the needs of service users. The week following this inspection thermostatic controls were to be fitted so that service users can control the heating in their bedrooms. Routine maintenance and repairs are undertaken on the building and a bedroom was in the process of being decorated at the time of this inspection. It is evident that staff work hard at providing a comfortable and homely environment for service users. The unit is decorated and furnished to a good standard and standards of hygiene are high. The home is accessible to all service users and ramps are provided to allow easy access to the building and grounds. The home has a large garden area to Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 18 the rear of the building which is well maintained. The building in general is need of some updating and a requirement has been made in previous inspection reports in relation to repairing and painting external window sills. During discussion with the Responsible Individual for the service it is planned that this will be addressed during this financial year. A further requirement was made in relation to guarding the exposed pipe work in the bathrooms and it is proposed that this will also be addressed during this financial year. In the interim risk assessments have been completed which are displayed in the bathrooms. A random sample of bedrooms were seen and a number were furnished with hospital beds and hoists in order that the differing needs of service users can be met. All rooms are centrally heated and pipe work and radiators are guarded. Thermostatic valves are fitted to a number of hot water outlets and water temperatures are tested. Thermometers are available in each bathroom so temperatures can be monitored. The home has separate laundry facilities and sluicing facilities are available on both floors. High standard of hygiene are maintained in the home and domestic staff should be commended for this. The home has the appropriate policies and procedures in place in relation to COSHH and Infection Control. Poulton House DS0000035570.V305027.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The quality in this outcome is good. This judgement has been made using available evidence including a site visit to the home. Recruitment and selection procedures ensure service user rights are protected. All new staff receive induction training, records indicate that mandatory and specialist training is provided to ensure staff can meet the needs of service users. EVIDENCE: The staff rota provided on the day of inspection, showed the number and skills mix of staff on duty and indicated that sufficient care and ancillary staff are deployed in order to ensure service users needs are met. At night the home provides three waking night staff. During the day there is always a member of the management team or a senior carer on duty. The home benefits from having a stable and experienced staff group, with a number of staff having been employed for a number of years. National Vocational Training is available to staff and the inspector informed by the manager that over 50 of staff had now achieved this qualification or above. The staff files of the two new members of staff employed since the last inspection contained evidence that they had received induction training. Evidence was also available that staff had received mandatory training and that it was renewed at appropriate intervals. Specialist training had also been provided that was relevant to their roles. Staff spoken to felt they worked well together, any issues that arose were discussed during individual supervision or at staff meetings and they also confirmed that they had access to regular training courses. Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 20 The organisation’s staffing department take the overall responsibility for managing the recruitment process of new staff. However, copies of CRB checks, references and application forms were kept at the home for information purposes. The records of three members of staff were checked including two new staff employed since the last inspection and showed that appropriate checks were made about staff before they started work at the home to ensure those appointed were suitable to work with vulnerable adults. Poulton House DS0000035570.V305027.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 33, 34, 35 and 38 The outcome in this standard is good. This judgement has been made using available evidence including a site visit to the service. The home is well managed and run in the interests of the service users. The home is well maintained to ensure the safety of service users. EVIDENCE: The registered manager of the home has many years experience of working in a residential setting, has obtained the Registered Managers Award and undertakes periodic training to up date her knowledge in relation to the legislation and good practice issues. Discussion with staff indicated that the manager provides clear leadership and staff felt supported. The manager of the home receives appropriate support and supervision from her line manager who is the Responsible Individual for the service. At the time Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 22 of the inspection the Responsible Individual popped into the home to speak to the manager and to ensure that everything was running smoothly. The home had a number of systems in place to gather information about the service provided and actively seeks the views of service users, as was evidenced from the comments and suggestions book provided. A leaflet is also included with the service user guide called “What do you think of your stay”. It was noted that a large number of thank you cards had been received by the home from past residents, relatives and visitors to the home. These were displayed on the notice board in the corridor and give prospective residents and visitors an opportunity to read comments made by people who have stayed at Poulton House. Regulation 26 visits are undertaken by the Responsible Individual and copies are forwarded to CSCI. An annual development plan had been produced as part of the home’s annual review that reflects the wider strategic aims of the local authority and plans for the future of the home. The Local Authority sets the budget for the home. Records of current financial transactions undertaken by the manager are held. The home does not routinely handle personal allowances for service users and currently only for the one resident who is staying at Poulton House on a long term basis. Where money is kept on behalf of residents, all transactions are recorded and receipts kept. Lockable facilities are available in all bedrooms. A random selection of records were examined these included fire safety which confirmed that the fire alarm and emergency lighting were tested regularly and staff receive training at the appropriate intervals, hoists and other equipment in use were regularly serviced. The Employers Liability Certificate was up to date. Information submitted prior to the inspection confirmed that all other safety checks had been carried out. Safe working practices have been developed and staff have been provided with the appropriate training to ensure service users and their own safety and well being is promoted and maintained. Poulton House DS0000035570.V305027.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 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 x x 3 3 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 3 3 x x 3 Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23(2)(b) Requirement The registered person must ensure that adequate action is taken in relation to the following: A significant number of external windowsills were found to have peeling paint. (Timescale of 07/04/05 and 28/02/06 not met) Timescale for action 07/02/07 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 OP7 Good Practice Recommendations That consideration be given to developing a single record where all issues affecting the service user including assistance and support given as part of the care plan are recorded. Poulton House DS0000035570.V305027.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Liverpool Local Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Poulton House DS0000035570.V305027.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. 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. 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