Inspection on 13/02/06 for Somerset House

This inspection was carried out on 13th February 2006.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Somerset House 17/02/09

Somerset House 18/10/06

Somerset House 04/11/05

Somerset House 09/03/05

Somerset House 24/08/04

Somerset House 03/03/04

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

CARE HOME ADULTS 18-65 Somerset House 17 Somerset Road Heaton Bolton Lancashire BL1 4NE Lead Inspector Lucy Burgess Unannounced Inspection 13th February 2006 10:30 Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 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 Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 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. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Somerset House Address 17 Somerset Road Heaton Bolton Lancashire BL1 4NE 01204 493126 01204 493126 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) Perpetual (Bolton) Ltd Mrs Tricia Varey Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th November 2005 Brief Description of the Service: Somerset House is a small care home providing residential care for up to 6 people with mental health needs. The home is part of a small group of two homes, the other being Hartington House. Both homes share the same staff team and are situated near to each other in the residential area of Heaton in Bolton. The main office base for the two homes is at Somerset House, although there is a small office at Hartington House. A local company, Perpetual Care, own the homes, with the day-to-day management carried out by the registered manager. Somerset House is an end terrace house, and comprises of six single bedrooms and communal areas. The home is close to a main road leading into Bolton town centre and is accessible to local transport. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day for a period of 4¼ hours. The inspector took the opportunity to look round the home, view records as well as talk with residents and staff. Discussion and feedback was also held with the Manager. The home is registered to provide accommodation for up to 6 people with mental health needs. At the time of the inspection there were no vacancies. What the service does well: What has improved since the last inspection? Training in relation to understanding mental health has been provided for some members of the team. This has provided staff with a good insight into the needs of residents and the support needed. Risk assessments have been developed in areas where concerns had arisen. These included residents’ safety due to falling and issues related to alcohol. Information has been placed on file and additional support accessed from another agency who provide help and advice about alcohol management. The medication system is safe and well managed. Regular checks are made, making sure that residents receive what has been prescribed for them and that records are up to date. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 Page 6 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. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 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 Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 The system of assessing prospective residents as well as spending time with them prior to admission gives an assurance that a resident will only be admitted if the home can meet their needs. EVIDENCE: Residents living at Somerset House have lived there for some time, therefore no recent placements have been made. However the process of resettlement followed by the manager involves both collating information and meeting with prospective residents. Information is requested from those health and social care professionals involved in assessing the mental health and support needs of individuals. The home also encourages prospective residents to visit the home. This enables both residents and staff to meet with each other as well as enabling further information to be gathered about their particular support needs, before making a decision in relation to the suitability of the placement. Once agreed, information gathered would be used to inform the development of the care plan. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Care plans had been updated and clearly identified the support needs of residents ensuring their health and well-being is maintained. Residents expressed they were settled and happy. Individuals are clearly involved in making decisions about their lives. EVIDENCE: Detailed information is held for each of the residents. Current care plans are easily accessible within the office with further information being held in a separate file. Information held includes risk assessments, formal review minutes, correspondence, health information, professional visits and daily evaluation sheets, which are used to monitor individual routines, diet, medication etc. Several areas are addressed within the care plans. These include physical and mental health, accommodation and personal care, family, formal and informal activities, finances, medication, faith and relationships with other residents. Within each areas individuals identify their goals, how these are to be achieved and a timescales for review. Plans had been reviewed on a 6 monthly basis or as needs changed. Residents are encouraged to sign their plan to evidence their agreement. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 Page 10 Information continues to be held with regards to the monitoring and review of individuals mental health needs. This is undertaken within the formal mental health reviews, which take place with the relevant social worker and health care professionals. Evidence was seen on file from a recent meeting. Reviews are carried out periodically throughout the year as agreed within the discharge programme and depending individual assessed needs. Psychiatric services continue to provide on-going support and advise to the team. One individual has recently joined a bi-polar group. The group consists of individuals who have the disorder, providing members with the opportunity to meet with others offering support, share information as well as developing relationships with other away from the home. Individual risk assessments are in place and address a number of areas specific to individual needs and safety. These include areas in relation to personal care, epilepsy/seizures, falls, alcohol and dietary needs. Assessments are reviewed and updated where necessary. Issues identified at the last inspection with regards to one of the residents have been addressed and additional support accessed. Changes were made to the Parkinson’s medication and support is being set up in relation to the alcohol issues. The resident appeared more settled and relaxed. The manager felt that improvements had been made to his confidence and general physical health due to the changes made. Routines are very much dependant on the residents motivational level and needs. Whilst some individuals are quite active other prefer a more relaxed routine. This has provided individuals with the emotional stability needed in maintaining their well-being. Those wishing to, can and do come and go freely. Activities away from the home include college courses, work placement, visiting the local pub and shops. As the home is relatively small, informal day-to-day contact is made between residents and staff with the views and opinions of both parties being easily aired. From discussions with residents and observation made, individuals appeared happy and relaxed. Whilst one enjoyed chatting about football, another was completing puzzles and doing his laundry. The new staff member spoken with was currently working through the homes induction process and was ‘shadowing’. The was enabling her to get to know the residents as well as the routine within the home. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 to 17 Residents have varied lifestyles depending on their individual choices and preferences. Residents access the local and wider community enabling them to lead valued lives, develop skills and increase their independence. Support is offered where required. Contact is maintained with family and friends and visiting is encouraged. The meals are good and offer choice, providing residents with a varied diet. EVIDENCE: Each of the residents living at Somerset House have routines based on their own choices and preferences. Whilst some individuals prefer to spend the majority of time at home, watching television, reading papers, using the computer, doing puzzles and relaxing, others follow interests away from the home. One resident attends college as well as undertaking supported employment. Another resident has recently joined a bi-polar group. This a service user group offering advice and support to its members. Residents also access local shops, take away and pubs, which are within walking distance of the home. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 Page 12 Each of the residents are encouraged to develop and maintain their independent living skills. Residents are involved with household tasks, including cooking, cleaning and laundry. Some residents take responsibility for certain tasks. Support is provided where required. Residents are supported to vote should they choose to do so. Mail is distributed unopened however appointments etc are passed to staff so that information can be recorded in the diary. Those wishing to follow their religion and culture are encouraged/supported in doing so. One resident continues to go to the paper shop each day to purchase newspapers. As already stated those residents who access the wider community have a bus pass and the home also has a vehicle, which can be used for both leisure activities and appointments. Some discussions have taken place with regards to this year’s holiday. Individuals have expressed that they would like to visit the Lake District again. One of the residents from Hartington House may also join the group. Contact with family and friends is also encouraged. Visitors are welcome to visit Somerset House at any time. Two of the service users also make regular visits to the family home. Individuals are able to see visitors in private using the large lounge or their bedrooms. Meals at the home are flexible. Support is offered where necessary ensuring individual follow a healthy diet. Those able and wishing too make their own arrangements with regards to breakfast and lunch. Generally the staff on duty prepare the evening meal. The home has a large kitchen where meals are eaten, however individuals are able to chose if they wish to eat elsewhere. Residents continue to have full access to the kitchen and may make themselves drinks and snack at any time should they wish. Cultural/religious preferences are also catered for. One service user follows a halal diet, each week he will inform staff of the food items need, which are then purchased when doing the weekly shopping. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Residents’ mental health needs are consistently met. Relationships with mental health professionals are effective and provide positive support networks for the residents ensuring their health needs are promoted. The medication system was found to be safe and staff have completed training ensuring residents are protected and practice is safe, minor improvements were needed to the records. EVIDENCE: As stated earlier information regarding the emotional and physical needs of residents are identified within the care plans. Where specific areas of risk have been identified these too have been assessed and information held on file. Records are made of all professional visits and appointments, which include GP’s, hospital, diabetic clinic, Parkinson nurse etc. Each resident has access to all NHS entitlements as and when they are needed. Support is offered for appointments. Should additional support be required with regards to maintaining the physical well-being of a resident, support would be accessed from the district nurse team ensuring that the necessary care and support is provided. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 Page 14 Previously issues were identified with regards to one resident being alcohol dependency. Contact has now been made with an agency offering support and advice in relation to the safe management of alcohol intake. A further visit is to be made next week where discussion will be made on what action/support can be provided. Other support networks include a Parkinson’s group where advice and support is provided by the nurse and a bi-polar group, which is run by MHIST, a mental health support group where people can meet together. As already stated the emotional/mental health needs of residents are monitored and reviewed by appropriate mental health professionals during regular review meetings. Individuals continue to be monitored through the Care Programme Plan. The mental health and well-being of residents is stable, where changes have been noted additional advice and support is sought from health professionals. Rising and retiring times are quite flexible. Residents are able to manage their own personal care needs however staff will prompt and offer encouragement where necessary, particularly with one resident who has a colostomy bag. Residents are also able to move around freely and do not require any physical support, therefore no aids have been fitted. The medication system was examined. The storage of medication was found to be safe. Records are made of all items received at the home as well as those returned to the supplying pharmacy. Monthly audits are also carried out on the medication records sheets, ensuring these are completed appropriately as well as monitoring medication administered to residents. It was found that staff are currently assisting one resident with the administration of skin cream however no records had been made. These should be completed. Risk assessments have been developed for those individuals who take medication whilst going on home leave. Information stated that individuals had been assessed in relation to their compliance however this had not been documented. The manager is advised to record how the individual has been assessed in relation to their compliance and what has informed their decision. A register continues to be held with regards to controlled drugs. Records are audited to ensure that stock reflects the medication held. Stock were found to be correct. The home also has a small separate fridge available should medication require refrigeration. Training has been provided for existing staff. Newer members of the team will need to complete relevant training in this area. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Clear procedures regarding the investigation of complaints and adult protection issues are in place, ensuring that residents were listened to and protected. Training is needed for the newest members of the team EVIDENCE: Clear policies and procedures are in place covering these standards. The home has developed its own policies and procedure in this area along with a copy of the Local Authorities Vulnerable Adults procedure. The team have some knowledge in relation to the procedure to follow and training has been provided. Further training is to be planned for the newest members of the team. No complaints have been raised with the CSCI. Additional policies and procedures in relation to adult protection are also in place. These include dealing with whistle blowing, aggression, service users finances and missing persons. Criminal Records checks are completed on all staff as part of the recruitment process. The owner is appointee for one resident, whilst other are supported by family or an appropriate representative. A random check was made with regards to the residents’ personal finances, which are held at the home. Records are made of all transactions and receipts held, balances corresponded with money held. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Somerset House continues to provide a comfortable, clean and homely environment for those living in the home. EVIDENCE: Somerset House is comfortable, homely and welcoming. The home is situated near to a main road leading into Bolton town centre and is easily accessible to public transport. The accommodation comprises of six single bedrooms, 2 bathrooms, 2 lounges, a conservatory, dining kitchen and small laundry room. There is also a staff office and sleep-in room provided on the ground floor. The homes designated smoking area is within the conservatory. The home’s laundry is situated along the hall away from the kitchen area. Each of the residents have a day set aside for their laundry, those who are able to manage independently, do so. The team supports those requiring assistance. Facilities are in place in both the kitchen and laundry for staff hand washing ensuring the prevention of cross infection. Cleaning materials are held within the laundry so that both residents and staff can easily access, as individuals Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 Page 17 are encouraged to take part in cleaning the home. Coshh assessments have been completed, however need to be reviewed and updated where necessary. The home also has a front garden and paved area to the rear with seating. Each of the residents spend time relaxing in all areas of the home. Bedrooms have been personalised with residents’ own belonging. Each have a key to their room. One resident spoken with expressed that he was happy with his room and ‘had everything he needed’. On the day of the visit the home was found to clean, tidy and free from odour. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Sufficient staffing levels and recruitment checks were in place ensuring the safety and protection of residents. On going training and support is being provided to equip staff with the knowledge and skills needed in meeting the needs of residents. EVIDENCE: Staff at the home support this project and those individuals who reside at Hartington House. The team comprises of the manager, two senior carers, permanent carers and bank (casual) staff. Single cover is provided with additional support from the manager during the day with a sleep-in staff member at night. The manager and senior carers also provide an on-call support service should any concerns arise or additional support be needed. Staff files were examined for 2 of the newer members of the team. Information was seen to include all relevant personal details, an application form, copies of identification and visa’s, references and interview records. Information was also held in relation to enhanced criminal record checks being completed. On-going training is in place. Recent courses have included TCI, which is in relation to behaviour management and intervention and 1st aid. Some members of the team have also attended training in relation to mental health needs and relevant legislation as well as what it’s like to have mental health Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 Page 19 problems from a service user perspective. Those staff that have already attended were said to found the course very useful and gave then a good overview of individual needs and behaviours. Further training is needed for some members of the team. Dates have been arranged for some staff to attend Pova training, TCI and 1st Aid. The manager is also to make arrangement for further courses in relation to mental health needs, providing staff with some insight into the needs of the residents residing at Somerset House. Medication training will also be required for the newest members of the team. The manager has also recently attended a conference on Health and Social Care Training facilitated by Bolton Council. This provides opportunities to access relevant training for care providers as well as sharing information in relation to management and policies and procedures. In relation to NVQ training this is being provided. Four staff members have completed level 2, whilst 2 are to commence the course. Arrangements are also being made for 3 staff to complete the level 3 training. The manager has gained the Level 4 in care and is to commence the Registered Managers Award, with completion later in the year. Supervision sessions have commenced. The manager and senior carers conduct these. Sessions are recorded and signed by both members of the team. The manager must ensure that all staff receive a minimum of 6 supervisions per year. Staff spoken with happy in their role and ‘enjoying it’. One staff members was on induction stated that she was undertaking some shadowing and ‘getting to know what the work involves’. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The overall management of the home is consistent and reliable for the people living there. Systems are in place for the reviewing of the service provision. A report regarding quality assurance should be developed and shared with all parties. Satisfactory arrangements are in place with regards to providing a safe, well maintained home so that residents and staff are safe from harm. EVIDENCE: The Residential Manager is responsible for the day-to-day management of both units, Hartington House and Somerset House. Training has been completed with regards to the Level 4 in Care. Commencement of the Registered Managers Award is to take place with completion this year. Other training courses related to the needs of service users have also been completed ensuring that her practice is up-to-date. The owner of the organisation supports the manager in her role. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 Page 21 Although there is no formal system in place for reporting feedback from stakeholders with regards to the overall service provided information is gathered in a number of ways. Residents have regular contact with the manager and feel able to discuss any matters or ideas they have. Residents were said to prefer the informality of 1-2-1 discussions as opposed to meetings. As the manager spends time in each of the units this enables her to speak with each resident on an on-going basis. Feedback is also sought from the staff during the periodic team meetings and supervisions. Additional comments are also received during the residents review meetings, which involve health and social care professionals. A recommendation was made during the inspection at the 2nd project in relation to a report regarding the development plans for both homes being written. The manager is to look into this. Regular checks are undertaken ensuring the safety of staff and residents. Up to date certificates were in place for • 5-year electric checks, • gas, • fire appliances and alarm, • emergency lighting • small appliances. Regular in-house checks are also made with regards to sounding the fire alarms, checking means of escape. Drills have previously been undertaken however not for some time. The manager is in the process of organising this and should ensure that this includes all new staff members. The fire officer also inspected the home in January 2006. Action identified has been addressed. As previously identified, Coshh assessments are in place, however need to be reviewed and updated ensuring information is accurate. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 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 3 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 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 2 X Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 Page 23 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 YA20 Regulation 13 Requirement That evidence is provided where residents have been assessed as being compliant with regards to the safe administration and management of medication when on home leave. That records are completed where staff assist residents with the administering of creams. That all staff complete training in the protection of vulnerable adults and medication. Timescale for action 31/03/06 2. 3. YA20 YA35 13 13 31/03/06 31/03/06 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. 3. Refer to Standard YA36 YA42 YA42 Good Practice Recommendations That all staff receive a minimum of six supervisions per year. That a recent fire drill is carried out and includes all staff employed since August 2004. That the Coshh assessments are reviewed and updated where necessary. Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Somerset House DS0000009321.V282915.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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