Inspection on 04/11/05 for Somerset House

This inspection was carried out on 4th November 2005.

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 4 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 13/02/06

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 4th November 2005 10:00 Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 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.V263792.R01.S.doc Version 5.0 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.V263792.R01.S.doc Version 5.0 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.V263792.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 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.V263792.R01.S.doc Version 5.0 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 5½ 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? Records held on staff have been developed to include all information and checks needed ensuring the residents are protected. Training has been provided in a number of areas including vulnerable adults, medication and mental health needs providing staff with the skills and knowledge needed for their role. The programme of induction for new staff has improved and looks at specific issues related to the residents, home environment and organisation. This give new staff a clear overview of the service and what is expected of them. Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 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.V263792.R01.S.doc Version 5.0 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.V263792.R01.S.doc Version 5.0 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): NONE EVIDENCE: The key standards will be addressed at the next inspection. Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 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 to 10 Care plans clearly identify the support needs of residents and how these should be met ensuring their health and well-being is maintained. Management strategies need developing with regards to identified risks ensuring staff and residents are safe. Residents expressed they were settled, happy and well cared for. clearly involved in making decisions about their lives. EVIDENCE: Detailed information is held for each of the residents and includes information with regards to their physical, emotional and mental well-being. Files were orderly and separated into specific areas. The care plan considers areas such as physical and mental health, family and social contact, personal support, education and training, communication, treatment and relationships with other residents. The current routines and needs of residents’ are clearly identified along with goals, interventions and timescales for reviews. 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.V263792.R01.S.doc Version 5.0 Page 10 They are Further information was also held with regards to formal mental health reviews, which had taken place with the relevant social worker. Minutes to meetings had been provided and copies held on file. Information clearly shows that the mental health needs, behaviours, routines and needs of residents were being monitored. Reviews were said to be carried out every 6 to 12 months depending individual assessed needs. The psychiatric services also provide on-going support and advise to the team. It was noted that the mental health needs of residents were in the main stable. One individual was a little unsettled however a care review had been arranged where these concerns would be discussed and appropriate action agreed in partnership with the resident and other relevant parties. Risk assessments have been completed in relation to personal care, epilepsy/seizures and dietary needs. Assessments need to be reviewed. Issues had been identified in relation to one of the resident who has Parkinson’s, is alcohol dependent and has had recent falls. Action has been taken along with health professionals to review the needs of the resident and provide the necessary support. The manager is advised to carry out a risk assessment in relation to the safety of the resident when away from the home. Additional records are also completed and include daily evaluation sheets. This information provides an overview of the daily routines of the residents including their medication intake, diet and behaviours. Residents are able to make decisions about their lives enabling them to increase their independence. Residents are able to come and go freely pursuing activities of their choosing and this was observed during the inspection. A couple of the residents follow various activities away from the home these include college courses, work placement, visiting the local pub and shops. Daily routines are based on individual preferences and motivational levels. 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. Residents also participate within monthly meetings. From feedback received and through observations made residents are happy with the support they receive. Interactions with staff were seen to be open and friendly. Residents expressed that ‘they were very settled’, ‘the new staff seem very nice’ and ‘we help each other out’. New staff spoken with confirmed that they had or were working through the homes induction process and had been made aware of the needs of the residents. Comments included ‘I feel I have learnt a lot’, ‘we get on great’, ‘the staff have been supportive’ and the ‘work is enjoyable’. Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 11 Clear information is held with regards to residents’ finances. Records are made of all transactions and receipts held. A random check was carried out, balances corresponded with money held. Information regarding the residents is held securely within the staff office. This is accessible to staff to refer to throughout the day. Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 12 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 Routines vary depending on 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. Residents maintain contact with family and friends and visiting is encouraged. The meals are good and offer choice, providing residents with a varied diet. EVIDENCE: Somerset House is situated off a main road and is easily accessible for the local buses to and from Bolton. There are also local shops, take away and pubs within walking distance of the home and the residents use these. Each of the residents follow a variety of activities both in and away from the home. Whilst some of the residents are quite active others prefer a more relaxed lifestyle. Routines are very much dependant on the needs and wishes of individuals. One of the residents is very active and has a work placement at Market Radio Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 13 and Asian Elders. He also attends college where is studying graphic design as well as attending a creative writing group. He has recently recorded poetry he has written onto CD as well as writing a news letter for the home. Other residents prefer to staff closer to home taking part in activities, which include going to the local pub, reading the paper, doing puzzles, occasional shopping trips, listening to music, watching TV and using the computer and Internet. 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. 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. Staff will offer support and advice when seeking out relevant employment opportunities or courses as well as making application for benefits. Newspapers are provided by the home, one residents continues to go to the paper shop each day to purchase the papers. 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. This year each of the residents enjoyed a summer holiday in the Lake District. A holiday cottage was rented and staff provided support. Residents spoken with expressed that they had enjoyed the break away. Contact with family and friends is also encouraged. Visitors are welcome to visit Somerset House at any time. Two of the service users make regular visits to the family home. Individuals are able to see visitor in private using the large lounge or their bedrooms. One residents was being supported by a befriending service to help find family members as contact had been lost. This was successful and contact is now made by the resident and his family including visits to the home. Meals at the home are flexible. Residents will make their own arrangements with regards to breakfast and lunch and staff support is provided where necessary. In relation to the evening meal the staff on duty prepare this. Meals are chosen each day and choices then recorded on the evaluation sheets held in each file. The home has a large kitchen where meals are generally eaten, however individuals are able to chose if they wish to eat elsewhere. Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 14 Where possible individuals are encouraged to eat a healthy diet. Residents 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 write a menu plan, which is then followed when shopping. The resident has recently taken part in religious festivals and continues to follow his faith as he chooses. Arrangements were being made for an Eid party for the residents, staff and family members. Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 15 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 to 21 The mental and physical health care needs are consistently met ensuring the residents health and well-being is maintained. Medication was stored and administered safely, however assessments need to be developed in relation to self-medication ensuring residents are safe. EVIDENCE: Each of the residents are able to manage their own personal care needs however at times staff will offer prompts and encouragement. Residents are able to move around freely and do not require any physical support, therefore no aids have been fitted. This would be kept under review and should needs change a referral would be made for needs to be assessed. Individual routines continue to be flexible. Most of the residents have a relaxed routine and therefore rise and retire as they choose. Residents have access to all healthcare professionals. A record is made of all appointments attended. Services accessed include GP, consultant psychiatrist, Parkinson nurses, diabetic clinic, community nurses, dentist and optician. Those resident who have diabetes are seen regularly for blood tests as well as additional health screening on their eyes and feet. Another resident has been diagnosed with Parkinson’s. Contact has been made with the nurses so that Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 16 additional guidance and monitoring can be made. Issues have also arisen with regards to alcohol dependency. A referral has been made to the alcohol support team so that further support can be accessed for the resident in addressing the concerns. Additional support is also accessed from the appropriate mental health professionals. Reviews are held every 6 to 12 months with their social worker. Individuals are 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. One resident has a stoma/colostomy bag, which he manages himself with prompts from staff. Information has been detailed within his file along with a risk assessment in relation cross infection. The home has a policy in place with regards to the recording, storing and administering of medication. The medication system was looked at and found to be safe. Medication is delivered on a monthly basis and records are made of all items received. Medication record sheets had been completed in full. Where had written prescriptions had been added to the sheets it is suggested that information is recorded in full stating the dose required and then checked and signed by two members of staff. A register is held with regards to controlled drugs. This is audited on a weekly basis ensuring the stock reflects the medication held. Staff have been informed that all medication records must be are signed following administration. A small separate fridge is available should medication require refrigeration. Whilst at the home staff take responsibility for the administering of all medication however it was noted that when residents have home leave alternative arrangements are made. Through discussion with the manager, medication for one of the residents is given to his mother to manage however should he stay with his brother this would be managed by the resident himself. A detailed risk assessment should be completed ensuring the resident fully understand the safe management and compliance with the medication. Recent medication training has been undertaken. Further sessions have been arranged for the newest members of the team. With regards to individual wishes in the event of illness and death this has yet to be fully explored. Each of the residents have lived at the home for a number of years therefore would be cared for as long as possible. All support services would be accessed ensuring that needs are met. Should the home have any concerns about a resident contact would be made with their next of kin. The manager is however going to explore this will the assistance of the advocate from MHIST, a mental health support service. Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 17 One of the residents has recently sold some property. The manager has supported the resident in speaking with a solicitor and financial advisor so that his affairs can be organised. Arrangement are also being made for a will to be written. Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 18 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 Systems were in place with regards to the investigation of complaints and adult protection issues, ensuring that residents were listened to and protected. EVIDENCE: Clear policies and procedures are in place covering these standards. A copy of the Local Authorities Vulnerable Adults procedure has been accessed. The team have some knowledge in relation to the procedure to follow and training has been completed. The newest members of the team will attend training later this month. Where issues have been raised by residents, information has been recorded and action taken where necessary. No complaints have been raised with the CSCI. The home also has further written policies and procedures for adult protection. These include dealing with whistle blowing, aggression, service users finances and missing persons. The majority of staff have a current Criminal Record Check in place. In relation to residents finances arrangements are made for personal money to be held at the home. Individuals have their own bank accounts. The owner or a family member are the appointee for most of the resident accounts. Records are made of all transactions and receipts held. A random check was carried out, balances corresponded with money held. Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 19 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 and 30 Somerset House provides a comfortable, clean and homely environment for those living in the home. EVIDENCE: Somerset House is an end terrace house and is indistinguishable from those around it. The home is close to a main road leading into Bolton town centre and is accessible to local transport. Accommodation comprises of six single bedrooms, 2 bathrooms, 2 lounges, a conservatory, dining kitchen and small laundry room. A staff office and sleep-in room is also provided on the ground floor. The home is comfortable, homely and welcoming. Redecoration and refurbishment of both bedrooms and communal rooms has taken place throughout the year, this has enhanced the appearance of the home. The exterior of the home was also tidy and clear from obstruction. 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. Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 20 The home’s laundry is situated along the hall away from the kitchen area. A number of the residents are able to manage their own laundry however staff assist those who require some support. Suitable arrangements have been made with regards to staff hand washing ensuring the prevention of cross infection. Additional cleaning items are stored in the laundry area and available to residents as individuals are encouraged to take part in cleaning the home. General risk assessments have been completed. On the day of the visit the home was found to clean, tidy and free from odour. Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 21 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, 33, 34 35 and 36 Recent recruitment ensures that sufficient numbers of staff are available to meet the needs of service users. Criminal records checks must be sought prior to employment ensuring the residents are protected. On-going training is provided enabling staff to develop the knowledge and skills needed in meeting the needs of service users. EVIDENCE: Individuals residing at Somerset House are physically able and do not require the assistance of staff. Support is very much on an emotional level. Several individual choose to pursue activities away from the home and do not require the support of staff. Staffing comprises of the manager, 2 seniors and 14 permanent or bank staff. The team work across two projects, these are Somerset House and Hartington House. Sufficient staffing is provided throughout the day and night to meet the needs of residents. Consideration would be given to the level of support provided if needs changed. Staff files were seen for the newest members of the team. Information was orderly and included all information outlined within the standards. This included an application form, full employment history, references, copies of identification and training certificates. It was noted that several individuals Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 22 had commenced work without application being made for a new criminal record check. Copies of previous documents had been received by the home. The home must ensure that new staff do not commence employment until such checks have been completed. Each of the newly appointed staff have been inducted into the home. This involved working through a booklet, which outlines expectations of them as an employee as well as developing their understanding of the needs of the residents and practices within the home. Video training is also completed in fire safety, health and safety and food hygiene. In addition to this staff will undertake the 1-day online TOPSS induction. Further formal training will then be identified and planned throughout the year. Recent training has included Crisis Intervention training (TCI), which is in relation to behaviour management and intervention, vulnerable adults, medication and mental health awareness. This was facilitated by an advocacy group called Patience Counsel and is facilitated by service users. Further training has been planned for the newest members of the team in relation to vulnerable adults and medication. Courses in diabetes, epilepsy, schizophrenia and bi-polar are also been looked into. These would provide the staff team with a good overview of the different needs of the residents. NVQ training has also been provided. Excluding the manager 4 members of the team have already completed the level 2 course and a further 4 have been identified for enrolment in January. The manager is exploring ways of funding the NVQ training needed. Support continues to be offered on a formal and informal basis. As the team is relatively small communication was said to be good. Two new members to the team expressed that they were enjoying the work and that ‘I’ve done a lot of shadowing so I know the routine’ and ‘I’ve learnt a lot’. A system of formal supervision is also in place. The manager and 2 senior support workers carry out these sessions. Records are made of all meetings and held on individual files. Information was found to include discussions around work practices, relationships within the team and areas of further development. Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 23 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): None EVIDENCE: The key standards will be addressed at the next inspection. Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Somerset House Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000009321.V263792.R01.S.doc Version 5.0 Page 25 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 YA9 Regulation 13 Requirement Timescale for action 30/11/05 2. YA9 13 3. YA20 13 4. YA34 19 That a risk assessment is developed in relation to incidents of falling and concerns regarding the personal safety of one resident That all individual risk 30/11/05 assessments are reviewed on an annual basis or more frequently if necessary That a risk assessment is 30/11/05 completed with regards to the safe administration and management of medication when a resident has home leave. The home must ensure the 30/12/05 criminal record checks/POVA checks are carried out for all new staff prior to them commencing employment 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 YA20 Good Practice Recommendations That hand written prescriptions are checked and signed by DS0000009321.V263792.R01.S.doc Version 5.0 Page 26 Somerset House 1. 2. 2. YA21 YA32 YA42 two members of staff. That individual wishes are explored with the advice and support from MHIST That NVQ training is routinely provided to the staff team That a recent fire drill is carried out and includes all staff employed since August 2004 Somerset House DS0000009321.V263792.R01.S.doc Version 5.0 Page 27 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.V263792.R01.S.doc Version 5.0 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!