Inspection on 15/07/08 for Poulton House

This inspection was carried out on 15th July 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Poulton House 13/10/06

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Poulton House Winterhey Avenue Wallasey Wirral CH44 4DX Lead Inspector Julie Garrity Unannounced Inspection 15th July 2008 11:00 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.V368408.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.V368408.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 barbaranorris@wirral.gov.uk 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.V368408.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) 13th October 2006 Date of last inspection Brief Description of the Service: Poulton House is a large, two storey building that was purpose built in the 70’s. The home is registered with the CSCI to provide care and accommodation for 38 people with age related needs. Parking is available to the front of the home. There is a large dining room, six lounges of a smaller size and a foyer area with additional sitting area. A separate room for visitors is also provided. All be bedroom are single none have ensuite facilities. People who stay in the home are there for a short time only some from hospital needing support before they go home and others there for a short stay. There is one person who has stayed there for sometime. Poulton House is situated in a quiet residential cul-de-sac, off a main road. It is easy to access by the Kingsway tunnel from Liverpool and a main motorway on the Wirral. Bus stops are located with five minutes walk and the local shops are located 10 minutes away with a larger shopping area in Wallasey village a 1o minute bus ride away. Poulton House DS0000035570.V368408.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 star. This means the people who use this service experience good quality outcomes. The site visit was carried out over a period of one day. We (the commission) arrived at the home at 10:45 and left at 17.30. The inspectors spoke with 7 people staying in the home, 2 external professional’s, 5 staff and the manager. We completed the inspection by a site visit to Poulton House, a review took place of many of the records available in the home and our offices. These included individuals care plans, assessments, accident records, staff rota, staff files, maintenance records, menus, staff rota, questionnaires, staff training, medications, information sent to us by Poulton House and a self-audit completed by the home. This site visit included discussions with people who live in the home, staff and management. Surveys were sent to staff and people using the service before the sit visit. None were returned from individuals who stayed in Poulton House. Eight were returned from staff. We followed an inspection plan that was written before the start of the inspection to make sure that all areas identified in need of review were covered. All of the Key standards were covered in this inspection, these are detailed in the report, additional standards were identified before and during the inspection these were also reviewed and detailed in the report. Feedback was given to the manager during and at the end of the inspection. The arrangements for equality and diversity were discussed during the visit and are detailed throughout this report. Particular emphasis was placed on the methods that the home used to determine individual needs, promote independence and support to make informed decisions in line with individual choices. What the service does well: Poulton House is a short term stay unit for people moving on from hospital or staying for a short time. The service has in put from a variety of professionals including physiotherapist, occupational therapist, consultant, dietician and district nurses as needed. There is a dedicated and caring management team that maintain a good quality of service. Poulton House DS0000035570.V368408.R01.S.doc Version 5.2 Page 6 Poulton House has a caring staff team that demonstrated through out the site visit the ability to communicate well with each other and the people who live in the service. Staff discuss the care of the people who stay in the home on a daily basis. People who stay in the home made positive comments about the staff these included, “welcoming”, “busy hard working staff” and “very friendly helpful staff”. There are a several lounges and sitting areas in the home that support individuals to spend the day were they would like to be. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Poulton House DS0000035570.V368408.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.V368408.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards reviewed were 1, 2, 3, 4 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service relies on external assessments and has taken individuals were the assessments indicate the home is not suitable to meet their needs. This places individuals at risk of not receiving care suitable to their individual needs. EVIDENCE: The people who stay in Poulton House are assessed by social services or the hospital before they move in. As the home supplies support to for short term care only this means that a lot of people will move in and out of the home each week. The manager explained that they did not have the resources to assess each of these themselves. The management team uses the assessments they get from outside the home and if they think they need to do their own assessments this is done. Poulton House DS0000035570.V368408.R01.S.doc Version 5.2 Page 9 The assessments from outside the home and from the services own staff do not always cover all the needs of the individuals before they move in. The assessments that were viewed did not include any social needs as an example. A letter was noted on an individuals file stating that the home was not able to meet their needs. The individual was admitted despite the concerns expressed. The manager explained that she had been told to admit the individual. It was also explained that this has happened on other occasions. Where all the information gathered about the needs of an individual indicates to the manager that the service will be unable to meet the individuals needs this person should not be placed at risk by moving into the home. Information in the home is not always available in formats that can meet the Individuals needs. People who use the service said ““ I have not seen anything about the home”, “did not know there was anything about it in my bedroom” and “was told this was were I was going until I was well enough to go home”. Three individuals discussed their experiences of moving in “I knew it was just for a little time so I was happy. I came here the staff were very nice they took me to a bedroom and helped me unpack.” “I don’t remember anybody talking to me about my needs and haven’t seen anything with it written down.” The home does send out an information pack that contains relevant information however important documents included in the pack are out of date. The manager explained that she is aware of the need to review this information and update it. A review of the home showed that the out of date information about the home is readily available in each persons bedroom. Poulton House DS0000035570.V368408.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards reviewed were 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and personal care needs are met; information for staff is not always clear and prevents them from being sure that they are supporting individuals in a manner to meet their needs. EVIDENCE: The service has short-term stay in the main. As such the majority of individuals are admitted for intermediate care before they return home. Part of the intermediate care facility is extensive in put from medical professionals such as a consultant, a physiotherapist, an occupational therapist, a dietician and district nurses as need. This means that the service has an every opportunity to access and gain in put to meet the medical needs of people they support. Two professionals were spoken with both were positive about the support from staff stating one said that “anyone coming here is very lucky”. Poulton House DS0000035570.V368408.R01.S.doc Version 5.2 Page 11 We looked at four care plans in two cases the individual’s for whom support from the care staff was being supplied had signed the care plan to agree with it. Two others had not and in two cases staff writing the care plans had not signed themselves. Care plans did not detail the care needs that individuals had or how staff were to meet them. One example included an individual who was admitted with a wound, the manager informed us that the district nurses were treating this. There was no details in the care plan as to how staff were to prevent a deterioration, what special equipment was being used, how staff were to contact district nurses if dressings needed replacing or how often the district nurses were to attend. Another example included an individual who had a diabetes. The manager explained that at times this was not stable and at those times staff gave them a milky drink and biscuits. There was a specialised treatment in the fridge of the home and the manager explained that this was for the district nurses. There was no information in the care plan as to how staff were to recognise the individuals signs and symptoms of a change in condition, what actions they needed to take, what involvement the district nurses were taking or when to contact the district nurses given that the condition was not stable. Care plans and assessments were contained in files in the main office and included a variety of information. Staff spoken with did not read the care plans that they did not write but did receive a verbal hand over each day in which they told about each individual currently staying in the home. One of the medical professionals explained that exercise plans are written for individuals living in the home and it was anticipated that staff carried out the instructions in place. She had observed staff doing so but was not aware of any records that showed that staff had delivered support as described in the plan. People spoken with said, “its been a nice stay and I do feel much better”, “not sure that staff all know what they are doing but they do ask me and talk to me about things”. “Not seen any plan of care, what is one of them”, “there are a lot of people here who help you out”, “staff work very hard always running around doing lots of things”. Without good care plans that are accessed by all staff involved, care staff may not be in a position to provide care that always meets individual needs. This is particularly relevant given that most individuals stay for a short time and as such staff do not always have the opportunity to get to know them as easily. We looked at medications management and noticed that all the individuals medications that we looked at did receive the medications that were prescribed. Some areas of best practice need to be undertaken in order to meet the diverse needs of individuals these were discussed in detail with the manager. Poulton House DS0000035570.V368408.R01.S.doc Version 5.2 Page 12 Examples would include better recording on the medication records, auditing of medications to maintain the competency of staff and arrangements in place to give homely remedies such as a paracetamol if an individual if they had pain. Currently if someone has a headache and is not prescribed a painkiller staff cannot attend to this need and must wait for a doctor to prescribe the paracetamol. This could be many hours if not days later. People who manage their medications themselves have been risk assessed. There is inconsistent practice around this aspect as there were other individuals managing some of their medications such as an inhaler without a risk assessment in place. Observations of the staff during the day showed that staff spoke to individuals in a calm and polite manner Poulton House DS0000035570.V368408.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 good. This judgement has been made using available evidence including a visit to this service. The serviced provides flexible routines and choices are available, all individuals are not aware of choices and supported to make those choices in a manner that meets their diverse needs. EVIDENCE: Menus were available on the main corridor. Menus did not show what choices were available for special diets diabetics as examples. There is a daily planner in the main dining room it tells the day and weather. The information for next meal said Tea, not what it was. All people spoken with had no idea what was available for the next meal “we never know what it is until we get it”. Others said, “did not know we had a choice, but sure if we asked could be done”. The chef was very clear that he would cook what ever was asked of him and that people could virtually have what they wanted. Records in the kitchen contained notes from the dietician regarding advice for individuals. The chef said that her input was invaluable and he was able to make sure that food available help matched need. Choices such as choice of meals are not widely advertised and as such individuals are not fully informed of the choices they have available. Poulton House DS0000035570.V368408.R01.S.doc Version 5.2 Page 14 Throughout the morning of this visit individuals were occupying themselves by reading, watching TV or chatting. There is no formal activities programme available. A number of individuals said, “just watch the television or talk to other people there isn’t a lot to do”. Records regarding rehabilitation activities such as “making a cup of tea”, which were started by the occupational therapist were not available and it was impossible to see what daily life activities the staff in the service were continuing to develop. The manager explained that as most people stay for a short time it is not always possible to provide activities additionally there is no activities co-ordinator available to do this. Lunchtime was briefly observed the dinning room was light airy and a nice place to eat lunch. Quiet music was playing in the background making it a pleasant experience. Drinks were readily available for all individuals. Opinions of the food varied but were generally. One person said “the food is fantastic”, “another said the meat is nice but vegetables are too hard” and a third said “I’m sure I have put weight on since I moved in”. Poulton House DS0000035570.V368408.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): Standards 16 and 18 were reviewed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are confident that their concerns will be listened to and addressed. The lack of a clear understanding of dealing with concerns of a serious nature will mean that staff may not pass on information or raise concerns in a suitable manner. Poulton House DS0000035570.V368408.R01.S.doc Version 5.2 Page 16 EVIDENCE: Poulton House is part of Wirral Social Services and uses the main complaints procedure and the accompanying leaflets from social services. This information is included in the information available in individuals bedrooms. The service has detailed policies and procedures to protect individuals from abuse. The majority of staff have not received training in this area for some significant time. Staff spoken with was aware of how to raise any concerns and who to raise these concerns with. However they were unaware of how these would be dealt with and ran the risk of inappropriately dealing with the initial concern raised. Discussions with senior staff showed that they were fully aware of how serious concerns are raised and how they would be dealt with. People staying in Poulton house spoken with told us that they believed that any concerns would be looked at and dealt with, one said, ““ if I had a problem I would tell the staff these are very good staff who work exceptional hard”. We have not received any complaints about this service. One concern was raised regarding additional services in the home. This was discussed with a representative of social services at the time and resolved. The manager explained that they have received one written complaint and that this is currently being dealt with by a senior manager. Poulton House DS0000035570.V368408.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): Standards reviewed were 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Poulton House provides people with a clean, comfortable and homely environment to stay in. EVIDENCE: There are a variety of lounges 6 in total were people sit and as such they can choose how to spend their day. One of the most popular areas is the main foyer on the way into the building. The variety of different spaces supports people to make a choice about where they would wish to spend their day. There is a large dining room and each floor has a small kitchen available to make coffee and tea if needed. The second floor has a special kitchen used by the people who live in the home to make drinks and some cooking as part of the actions to return home. Poulton House DS0000035570.V368408.R01.S.doc Version 5.2 Page 18 All the bedrooms are single bedrooms and none have ensuite facilities. There are plenty of toilets and bathroom throughout the home. The equipment in each is old but is maintained very well and continues to function safely. All equipment checks are in place. Information sent to us before the site visit showed that all checks such as electrical and gas had been completed properly. The kitchen and laundry door were wedged open for the entire duration of the site visit, the kitchen with a rolled up newspaper. This is not safe practice and does not help prevent the spread of fire of one occurred. The home was generally clean. Individuals said, “it’s a very nice home, rooms are a little small but you expect that don’t you”. “ Its very clean and tidy, what more can I ask”. “I like the dining room its lovely”. A review of the home showed that wallpaper was lifting in some places and wood work was a little scuffed. But in general was homely, decorated in a style in keeping with an individuals own home and clean and tidy. The manager informed me that until recently there had be a refurbishment and redecoration programme but this had been cancelled following the decision that in the future the home will change status close or be sold. In general the bedrooms viewed were clean and tidy. As the people who stay in the homed tend to be there for a short time only they do not personalise the bedrooms very much and don’t bring in many of their own items. Poulton House DS0000035570.V368408.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): Standards reviewed were 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment of staff makes sure that staff are properly checked before they start working in the home. Staff do not always have up to date training and skills to meet the diverse needs of the individuals they support. EVIDENCE: The manager explained that staff training had not happened in the last few months. We looked at the training records and noted that some staff had received medications training but all the other records showed that no training had taken place for sometime. This included health and safety training, moving and handling training and adult protection training. Fire safety training had taken place. This means that some staff do not have the skills that they need to safely undertake their job role. Questionnaires were received from staff before the site visit this also confirmed that whilst the majority of staff thought that they had the skills on occasions some staff thought they did sometimes. The manager explained that the service can have lots of people moving in and out and this can influence how many staff they need. There is no formal means to monitor the staff other than if the manager feel more staff are needed this can be arranged. Poulton House DS0000035570.V368408.R01.S.doc Version 5.2 Page 20 We spoke with several people staying in Poulton House. All made very positive comments about the staff ““the staff work very hard and are always very busy, just look at them running around trying to do everything”, “they are very nice staff, very pleasant, friendly I will miss them all” and “If I ever have to come back again I would be happy to do so as everyone is so nice”. We looked at staff recruitment and found that all staff had been checked properly before they started working. Staffing files had copies of induction records in all cases these were brief and were an orientation to the home. The manager said that there are plans to change this in the future and make the inductions longer giving more information about the needs of people who use the service. Poulton House DS0000035570.V368408.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): Standards reviewed were 31, 32, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a large input from a variety of professionals that support the service to maintain standards. A dedicated and competent management team have help to maintain standards. The lack of an opportunity to determine the quality of a service has prevented the service from continuing to increase the quality of support that they provide. EVIDENCE: Staff spoken with thought that manager and the management team were “excellent”, “they really stick up for us and try to make sure that we get what we need for the people we care for”. Poulton House DS0000035570.V368408.R01.S.doc Version 5.2 Page 22 People staying in the home said, “this is a good place to stay”, “I couldn’t ask for anything better the care has been second to none”. Professionals spoken with also clearly stated that the service was good. That the majority of people left the home having been given the opportunity to recover and that the statistics that they regularly review reflected that. Regular professional meetings discussed the care of the majority of individuals and their progress in returning home. The input of a wide variety of professionals has meant that quality of the service has been maintained. The information sent to us by the manager was incomplete and did not detail what plans the service had in place to recognise and increase the quality of the service they provide. Additionally the home has no quality processes in place such as checking on the quality of care plans, monitoring and maintaining staff training or formally reviewing staffing levels. As such it will be difficult for the service to determine its strength and to progress areas that need further development. Questionnaires for people leaving the service are available the manager stated that these are rarely filled out and as such they do not often get an opinion of what people think of the services. As most people only stay for a short time the home does not access individual personal allowances. They do however hold small amounts of money for people that families ask them to. Receipts of any spending are kept to make sure that the funds can be accounted for. Poulton House DS0000035570.V368408.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 2 3 3 2 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 2 Poulton House DS0000035570.V368408.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. 1. Standard OP7 Timescale for action 15 (1) (2) Care plans need to be reviewed 15/10/08 (a) (b) (c) and contain clear guidance to (d) staff as to how to meet individual needs. Plans need to be signed by those involved in writing the care plan in order that the individual is fully aware of the support that is to be provided. 18 (1) (a) Staff training needs to be 15/10/08 (2) reviewed and a training plan generated with dates of completion for all staff out of date in moving and handling, first aid and health and safety training. Other training such as adult protection and training specific to the needs of individuals also needs to be developed. 24 (1) (a) The service needs to put into 15/01/09 (b) (2) (3) place a system to identify the quality of the service and form a plan that increases the quality of the service provided. Regulation Requirement 2. OP27 3. OP33 Poulton House DS0000035570.V368408.R01.S.doc Version 5.2 Page 25 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 OP3 OP9 Good Practice Recommendations Were assessments indicate that the home can not meet the needs of an individual the manager needs to make sure that the individual is not admitted to the home. Medication records need to be developed to include all label directions, records of external preparations used and risk assessments for any medications that individuals hold themselves. The service needs to develop a plan to review the environment and show how areas that are deteriorating will be addressed. The home needs to consult with the fire authority with regards to the wedged open fire doors. 3. 4. OP19 OP38 Poulton House DS0000035570.V368408.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Poulton House DS0000035570.V368408.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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