Inspection on 31/05/06 for St Philips Close

This inspection was carried out on 31st May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Philips Close 24/04/07

St Philips Close 29/11/05

St Philips Close 19/07/05

St Philips Close 01/02/05

St Philips Close 29/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 St Philips Close 3 St Philips Close Middleton Leeds West Yorkshire LS10 3TR Lead Inspector Dawn Navesey Key Unannounced Inspection 31st May 2006 09:30 St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Philips Close Address 3 St Philips Close Middleton Leeds West Yorkshire LS10 3TR 0113 277 8068 0113 2778068 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) londonroad@tiscali.co.uk Milbury Care Services Limited Care Home 4 Category(ies) of Learning disability (4) registration, with number of places St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: 3 St Philips Close is a purpose built bungalow located in a residential area of Middleton close to local amenities and public transport routes. There is roadside parking to the front of the home. There are well maintained gardens to the rear of the property that are accessible to service users. The home is registered to provide personal care for four people with learning disabilities. The accommodation includes four single bedrooms, a lounge, combined kitchen and dining room, a communal bathroom and toilet, a domestic style kitchen and separate laundry room. The current scale of charges at the home is £8,730.60 per annum. Additional charges are made for toiletries, magazines, outings, activities and taxis for college. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two inspectors between 930am and 5pm. The purpose of this inspection was to monitor progress in meeting the requirements and recommendations made at the last inspection, and to make sure the home was providing a good standard of care for the people living there. The people who live at the home prefer the term service user; therefore this will be used throughout the report. The methods used at this inspection included looking at care records, observing working practices and talking to service users and staff. Most of the service users have complex needs and discussion with them was limited as they do not use verbal communication. However, some of the staff on duty had known the service users for many years and have a good knowledge of their needs and how they show their likes and dislikes. Information gained from a pre-inspection questionnaire and the home’s service history records were also used. Comment cards were left at the home to provide service users and visitors with the opportunity to comment on the service. Feedback was given to the Manager at the end of the inspection. Requirements and recommendations made during this visit, and outstanding from previous inspection visits can be found at the end of this report. What the service does well: The home has a high standard of decoration and furnishings. Each service users’ room is individual to them and shows their interests and preferences are catered for. Staff make sure that service users have regular and varied activities and write this in daily records. Staff are good at encouraging family involvement and were able to talk to service users about their family, showing they had good knowledge of them and had built up good relationships. One of the relatives said “I feel lucky my son is within five minutes of my home, I am always made to feel so welcome here.” St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 6 The home has a flexible approach to meeting service users’ needs. This makes sure that service users receive individualised care and can make choices about what they do. Staff and service users have a good relationship and there is a relaxed atmosphere in the home. What has improved since the last inspection? What they could do better: The home’s statement of purpose must be individual to this service. Contracts for service users must be reviewed and updated. Care plans must be further developed so that they are clear and give detailed information on service users’ needs and how these will be met. Care plans must also be reviewed to make sure the plan is still meeting the person’s needs. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 7 All identified risks must be assessed with an action plan put in place to show how risk is minimised. The home must address a number of staff training needs. These include, accredited medication training, to improve some of the poor practices around medication administration and record keeping. Also, training on the specialist needs of service users must be provided. Staff must follow proper hygiene procedures to prevent the spread of infection. The home must address health and safety issues, such as, making sure risk assessments are carried out for hazards identified around the home and proper completion of accident record reports. The home must have an effective quality assurance system, which seeks the views of service users and their representatives, to make sure there is continuous improvement in the service. Some consideration should be given to providing information in a format that is more accessible to service users, examples being, the complaints procedure and service users’ contracts. Staffing levels and service users’ dependency levels should be reviewed to safeguard service users and staff and to make sure activities for service users are maintained. A number of requirements and recommendations have been made to address these issues. They can be found at the end of the report. 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. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 8 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 St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 9 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): 1,2,3 and 5 Service users and their representatives now have sufficient information available to them to make an informed choice about the home EVIDENCE: The Statement of Purpose is available at the home, it includes some pictures but is in very small print, making it difficult to read. It was also not individual to the service at 3 St Philips Close. The home manager said she has produced a new service user guide with pictures and words, in an attempt to make this accessible for the current service users, however this was not available on the day of the inspection. Contracts were seen, these are not accessible, contained out of date information and need to be reviewed. Pre-admission assessments are referred to in the service users’ agreements. A service users’ relative said she had been involved in the choice of home for her son and said I feel lucky he is within five minutes of my home. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 10 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 and 9 Not all care plans provide clear information on how needs are to be met but the recent audits show how this will be addressed in the future. Risk assessments are not carried out for identified needs and hazards. Service users are involved in the day to day running of the home and can influence what happens there. EVIDENCE: There was some excellent information in some service users care plans such as communication diaries, pen pictures and life histories. These were mainly written in the first person which is good practice. However, the format of the current assessments and care plans is difficult to follow. Some service users had assessments of their needs which were not dated. Some had care plans written that did not seem to come from any assessed need. Plans were mainly focussed on physical, practical care needs and were not person centred. They St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 11 didnt highlight service users hopes and dreams or likes and dislikes. Care plan information for some service users had not been reviewed for over a year. Staff said that they were currently introducing a monthly keyworker reporting/meeting system. There were no formal reviews on file for any service user or any evidence of family involvement in this process. Daily notes were written for each service user. Despite the gaps in documented care planning, staff were aware of the needs of service users and were seen to support them properly. Staff said they had recently had training from the home manager on care planning and risk assessment. Full risk assessments have still not been carried out for most of the service users. It was evident that risks do exist but they have not been formally identified and properly assesed. The home manager is fully aware of the lack of written care plans and risk assessments and has taken steps to address this. All service users’ files have been audited and she has developed an action plan for keyworkers and herself to work on. The manager will also be doing some person centred planning with service users to make sure their hopes and dreams are also identified. Staff gave examples of how service users are involved in the day to day running of the home. Service users choose what to wear, choose the colours of the decoration in the home and what to eat. They also benefit from the more flexible approach introduced by the new manager. Service users can choose to have a lie in when they want one. The home manager also uses information received from service users to monitor staffs performance. A service user’s relative is a regular visitor to the home. We observed how welcome and involved she was at the home. Staff said they encourage this contact and tell relatives and friends they can visit anytime. Staff also spend time with service users to try and find out their preferences. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 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): 12,13,14,15,16 and 17 Service users have varied and regular activity appropriate to their needs and preferences. Staff encourage and support service users to maintain relationships with their families and within the community. Service users are served a healthy, balanced diet. EVIDENCE: A variety of activity is on offer to service users. This ranged from activity offered within the home , organised activity such as Gateway clubs and activity and leisure opportunities within the community such as shopping, and trips to the park. Staff said they sometimes felt limited by the staffing numbers, there only being 2 staff on each shift during the day. They said they often have to take St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 13 two people out together when 1-1 would be better. The home does not have its own transport anymore. Service users use buses and taxis. None of the current service users follow a religious faith. The home manager said she would endeavour to meet any cultural or spiritual needs that people had. She said that one service user has a regular mens night out. All service users have an annual holiday, suitable to their preferences and needs. Nothing has been arranged for this year yet due to permanent staffs availability. Staff have now been employed so holidays will be arranged. Service users are assisted to maintain family contacts by telephoning them, visiting them and inviting them to the home. One relative said I am always made welcome and offered refreshments. Arrangements have been made for a service user to visit his Mum and sisters homes with the support of his keyworker. Another service user has a friend who lives in the home next door. They visit each other and go out together. Staff were able to say how they maintain independence for service users and how their flexible approach to routines benefits them. One service user comfirmed this saying how he was supported with privacy and dignity during personal care. Staff were seen to support people with dignity and respect at all times. A service user confirmed that staff always knock on his door and wait to be asked in. The menus and choices available within the home have improved. Fresh produce is now readily available and service users’ likes and dislikes are catered for. A cooked breakfast is available every day if wanted, lunch is usually a snack type meal and the evening meal is the main cooked meal of the day. This is seen as a social occasion and everyone sits down together around the dining room table. Staff said that this is enjoyed by all service users. Sandwiches followed by fresh fruit were served at lunch time. Staff said they aim to provide the recommended 5 pieces of fruit and vegetables per day. Staff were aware of how to get a dietician for service users if they needed one and had sought the advice of the GP before a service user went on to weight watchers diet. Service users are involved in menu choices through staffs observation of their likes and dislikes and by asking them what they want. They are also involved in the weekly shopping. Service users were assisted with their meals with courtesy and respect. There was plenty of social interaction between staff and service users throughout their meal. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 14 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): 18,19,20 and 21 Personal and healthcare support is provided in a way that meets service user’s needs. Service users are not properly protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Stafff supported people with personal care needs in private. They said they were aware of service users needs through their knowledge of them rather than what is written in the care plans. Service users had details on file of health professionals they are involved with e.g. GP, District Nurse, Dentist, Chiropodist. The manager said that service users have at least an annual health check and their medication reviewed annually. The home uses a monitored dosage, pre-packed system for the medicines. Only senior staff are responsible for the administration of medicines. There St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 15 are no facilities for the storage of controlled drugs, should they be needed. The home does not use homely remedies and therefore do not have a policy for this. The medication cupboard had medication in stock that was not on the service users administration records. This should have been returned to the pharmacy. Medication entered on the administration record was at times handwritten but not countersigned by two people. No record is kept in the house of medication that has been ordered so there is no way of knowing if there are any mistakes. There was no list of staffs specimen signatures for medication administration. There is a policy on medication, however this had a list of abbreviations which should not be used. Staff said they had completed a half day training on medication, however the manager does not feel this is sufficient and has arranged for staff to undertake an accredited distance learning course in September 2006. Some service users had plans in place for their funeral arrangements. The home manager said she will incorporate last wishes and funeral plans into the person centred planning she intends to do. No staff have had any training relating to ageing, death and dying or the changing needs of service users. The home manager, however, has this training arranged for July 2006. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 16 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 There are systems in place to make sure service users are protected from abuse. Service users views are respected and encouraged. EVIDENCE: The home has an easy words complaints procedure for service users. How to complain is also covered in the service user guide. A complaint received this year had been handled properly. Staff and a visitor to the home were aware of the complaints procedure and who to complain to. Staff said they had recently had training on the protection of vulnerable adults. They could describe different types of abuse and how to respond to suspicions or allegations of abuse. Some staff were not clear on what to do if this was out of hours and would benefit from training on how to use the multi-agency abuse procedures. A recent adult protection issue has been properly addressed and investigated by the home. Procedures have been reviewed with regard to service users’ bank accounts and who can access money on their behalf. Finance records were well maintained. Monies are stored safely and proper handovers take place. The home manager checks receipts on a weekly and monthly basis. The operations manager also checks them on her visits. Each service user has their own bank account. Senior staff are the signatories and St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 17 must provide identification each time withdrawals are made on behalf of service users. The home manager is going on benefits training so she can be sure that service users are getting all they are entitled to. The bank accounts of deceased service users are now closed. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 18 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 Service users live in a homely, comfortable and clean environment. Some practices increase the risk of the spread of infection. EVIDENCE: The home is nicely decorated, well furnished and very homely. All service users have their own room which reflects their individual taste and interests. One service user’s relative chose to decorate the bedroom himself. Service users’ bedrooms all had a sink but there was no liquid soap or paper towels for hand drying. The home is warm, clean and airy with a good layout. There was a hi-lo bath and tracking hoist in the bathroom to assist service users. There were a number of infection control isssues that the home must address. The clinical waste bin, in the bathroom was not foot operated and incontinence St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 19 pads were not being double wrapped. There were also no paper towels for hand drying. There is also a shower room which some service users prefer. Towels were stored on an open shelf, which increases the risk of cross infection. The clinical waste bin in here was also not foot operated. Soiled linen is washed on the premises. Staff transfer soiled linen from a yellow bag into the washing machine. This practice increases the risk of infection. Staff were not aware of water soluble bags. Staff said they had been trained on infection control. Staff were seen to assist service users at the toilet wearing gloves but not protective aprons. The laundry room was clean and tidy, however some washing tablets were found to be stored in an unlocked shelf unit. Due to packaging, these could be mistaken for something edible and should be stored more safely. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 20 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 Staff appear to be competent and understand the needs of the service users despite the gaps in training. Staff are beginning to work well as a team and being given the support and supervision to do this Staffing levels need to be reviewed to ensure service users needs are fully met. EVIDENCE: Staff complete induction workbooks under the supervision of the home manager. Training courses are then used to back this up. Whilst there are some gaps in staffs training, the manager has recently undertaken an audit of staffs training needs and is booking training courses. The organisation cannot supply enough places for staffs needs so local resources are being looked into. Training updates such as first aid and food hygiene are needed for some staff. 40 of the staff team have an NVQ (National Vocational Qualification). Another 2 staff are currently undertaking this. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 21 Staff and the manager all felt that there had been improvements in teamwork and communication in the last few months. Team meetings are taking place monthly and more often if needed. Staff are receiving regular supervision. The manager must make sure she provides supervision for night workers. Staff said they feel they meet the needs of service users but the staffing levels affect their ability to get out more often with service users, especially on a 1-1 basis. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 22 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): 37,38,39,41 and 42 A manager has now been appointed on a permanent basis to provide leadership and direction to the home. Some of the homes practices with regard to policies, procedures and record keeping do not promote health and safety. EVIDENCE: The manager has now been appointed on a permananent basis and has requested a pack for registration as the registered manager. The home did not have a permanent manager in place for over a year prior to this appointment. She is currently undertaking the registered managers award and will follow this with the NVQ 4 in care. The manager is allocated 20 hours administration time to oversee this home and the one next door. The rest of the time she is not supernumary. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 23 Regulation 26 visits are carried out by the organisations operations manager. These are not always done monthly or individually for this bungalow. The homes Statement of Purpose makes a brief reference to the companys Quality Assurance systems but does not state how this will be carried out. All services within the organisation receive an annual service review. This has not taken place at this home. Staff have access to a range of policies and procedures E.g. handling complaints, medication, risk assessment and accident reporting. Some of the homes record keeping needs to improve. Accident records were incomplete and had no follow up information on them. There were no environmental risk assessments done for hazards within the home. COSHH records were well kept and up to date . Staff said they had received training on moving and handling and fire safety. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 3 4 X 5 3 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 2 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 x LIFESTYLES Standard No Score 11 X 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 3 2 3 2 X 2 2 x St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Each service user must have a clear and detailed care plan, which identifies all their needs and how they will be met in a person centred way. The previous timescales of 31/03/05, 9/10/05 and 31/01/06 have not been met 2. YA9 13 All identified risk must be assessed with an action plan in place to minimise the risk. The previous timescales of 30/03/05, 9/10/05 and 31/01/06 have not been met. 3. YA20 YA35 13 Staff must receive accredited training on the safe handling of medications in order to improve practice. A risk assessment must be completed to show how any risk of cross infection is minimised when storing towels on an open shelf in the bathroom. 01/09/06 07/08/06 Timescale for action 07/08/06 4. YA30 13 07/07/06 St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 26 The clinical waste bins must be foot operated. Incontinence pads must be double wrapped before being placed in the clinical waste bin. The practice of transferring soiled linen from yellow clinical waste bags into the washing machine must cease. The home must use water-soluble bags that go straight into the machine. Aprons must be worn when assisting service users at the toilet or in the bathroom. Liquid soap and paper towels must be provided in each service users bedroom. The organisation must make sure that 50 of the care staff achieve an NVQ. Night staff must receive regular supervision. Visits by the registered provider must take place on a monthly basis and individually for this registered home. 5. YA32 18 31/12/06 6. YA36 18 30/06/06 7. YA39 26 30/06/06 8. YA39 24 The home must have a quality 07/08/06 assurance system in place, which seeks feedback from service users and their representatives. Accident reports must be fully completed with details of the accident and any follow up or outcome to the accident. Accident reports must be analysed to identify patterns and trends. 07/08/06 9. YA41 YA42 13 St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 27 Records must show service histories of equipment used in the home and any maintainence work carried out. Identified hazards within the home must be supported by a risk assessment and action plan. 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 YA1 Good Practice Recommendations The home’s statement of purpose should be individual to this home. Some further consideration should be given to making this accessible to service users. Contracts for service users should be reviewed. 2 YA20 Staff should be provided with a medication procedure which is in line with the Royal Pharmaceutical Guidelines. The manager should consider having a homely remedies policy and procedure. 3 4 5 YA23 YA30 YA32 YA38 YA33 Staff should be trained in the use of the multi-agency procedures in relation to protection from abuse. Washing tablets should be stored more securely to ensure they are not mistaken for something edible. Staffing levels should be reviewed to make sure there are enough staff to ensure a good level of activity for service users and a proper response to emergencies. This review should show how the manager provides management and leadership to both homes when included in the numbers of staff available. St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 St Philips Close DS0000001501.V296070.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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