Inspection on 19/04/07 for The Boundary

This inspection was carried out on 19th April 2007.

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

Other inspections for this house

The Boundary 25/04/06

The Boundary 09/02/06

The Boundary 09/08/05

The Boundary 01/02/05

The Boundary 20/07/04

The Boundary 22/01/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 The Boundary 418 Parrswood Road East Didsbury Manchester M20 9GP Lead Inspector Joe Kenny Unannounced Inspection 19th April 2007 10:00 The Boundary DS0000021605.V334544.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 The Boundary DS0000021605.V334544.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. The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Boundary Address 418 Parrswood Road East Didsbury Manchester M20 9GP 0161 445 0422 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) Mrs Teresa Williams Mrs Joan Elizabeth Ford Care Home 12 Category(ies) of Learning disability (12) registration, with number of places The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user is aged 65 years or over. Should this service user leave the home the place will revert to the service user category Learning disability (LD). 24th January 2007 Date of last inspection Brief Description of the Service: The Boundary is a home providing accommodation and personal care for 12 adults with a learning disability. It is made up of two semi-detached houses converted into one to form a detached property. The home has a paved area at the front with parking for approximately three cars. The home also has a conservatory and a large rear garden with seating and shaded areas. The garage situated at the rear of the property is used for storage. Accommodation at The Boundary consists of eight single and two double bedrooms. There are two adjoining lounge areas, a kitchen and a large conservatory, which is used as a dining area and for activities. The home is situated in a residential area of West Didsbury, close to public transport routes into the city centre and surrounding areas. A railway station is less than five minutes walk from the home. The area has a good range of all the usual services, including shops, a post office and public houses etc. A large supermarket and a leisure park is situated less than five minutes walk from the home and there is a corner shop nearby, which is convenient for the people who live there. The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit carried out as a key inspection on the 19 April 2007 and provided the opportunity to look at the National Minimum Standards for care homes supporting people with a Learning disability to determine how the home was meeting required standards. Information provided by the home in the period since the last inspection and prior to this was examined along with comment cards returned by people who live in the home. During the course of the visit time was spent in discussions with staff and people, who use the service, inspecting records relating to the management of the home and care plans. A tour of the premises was undertaken. Information on the day of the visit indicated the home had taken steps to address requirements made as a result of previous visits. Requirements not addressed will be repeated in this report. The weekly fees for the home are £500 to £650. What the service does well: Information about the home and procedures to support people considering moving to the home were clearly developed to ensure information about the care they required was received by the home. The manager and deputy manager confirmed they would visit the prospective person and give them the opportunity to visit the home. People living in the home confirmed that they had the information and support of relatives to assist them at the time they moved to the home. Records and comments by people living in the home on the day and through comment cards received prior to the visit indicated that the home met their heath, personal and social interests. This was also evident in observations of people moving in and out of the home on planned activities. On the day of this visit there was evidence that people are encouraged to make choices about how they spent their day and had access to a number of community resources such as day centres, cinemas and leisure centres. People also confirmed they are encouraged to be actively involved and participate in day to day domestic routines within the home. It was evident that the outcomes for people living in the home were to enable them to develop daily living skills, set objectives for the future and to maintain contact with family members and the community they live in. The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 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 The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good; This judgement has been made using available evidence including a visit to this service. People are provided with the information and support they need to make an informed choice as to where they live. EVIDENCE: There were no vacancies at the home and no new admissions over a long period of time. The information provided to the inspector demonstrated that the home had developed a statement of purpose and service user guide, which would be given to any person enquiring about the home. Copies of these documents were seen at the time of this visit. The manager and deputy manager gave a clear account of the action taken to support a person considering moving to the home if and when a vacancy was available. This included gathering information from the placing social worker and completion of the homes own internal assessment and care planning form when visiting the person referred to the home. The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 9 The manager clearly indicated that the home would ensure the person referred had been offered the opportunity to visit the home on a trial basis and had also been offered the opportunity to visit other services to ensure choices were available to the individual. It was evident from comments by staff and people living at the home that contact is maintained with family and that family members supported a number of people when they initially moved to the home. The home was advised to ensure that each person living in the home had a statement of the terms and condition of their placement, in line with standard 5 of the National Minimum Standards. This statement should be held on each person’s individual file. Ten people responded through the comment cards. Nine people confirmed they received information about the home and chose to move there. Most indicated they were supported by a relative in making a decision to move there. One person indicated they had not received information about the home, however the person’s comments in relation to other topics in the survey demonstrated that they were happy with the care and support offered by staff. People living in the home completed the majority of comment cards in person; their key worker supported others. People commented, “I am very happy living here”, all commented that staff were very supportive. The Boundary DS0000021605.V334544.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflected the needs, abilities and choices of people living at the home. EVIDENCE: Files contained information from the time of admission and included information from the placing social worker. In addition there was evidence of completed assessments undertaken by staff from the home. The files of two people using the service were examined to evaluate information held from the time of admission, how it was reviewed, leading to their current support plan. Information was detailed and set out how the person should be supported. The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 11 On examination of a sample files it was noted that some review forms were not dated. All forms should be dated to ensure the review process is held at regular intervals. Daily recordings by staff were informative and indicated the home had developed recording procedures to give greater information about how individuals support plan, goals and needs were being met. The manager and deputy manager had commenced the process of developing and reviewing care plans. The review process had not been completed for all files. The management team is advised to complete this process in order to ensure people’s needs are being met and to support the positive work being undertaken by the home. This work was initially carried out by key workers. There is a need to evidence that people using the service have signed up to the records to confirm it reflects their personal preferences. Where a person may need the support of a relative, their signature should be retained on record. Comments by people living in the home, on the day and through comment cards, were positive and people spoke about their involvement in the home and choices available for leisure and social interests. People are consulted about such matters individually or in group meetings. It was encouraging to note that people who live in the home make the records of such meetings. On the evening of the inspection people were observed to be involved in activities of interest to them and would spend the remainder of the evening watching their favourite television programmes in the lounge. The Boundary DS0000021605.V334544.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16,and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for all aspects of daily living reflected the individual choices and ability of people in relation to domestic and community based activities. EVIDENCE: The lifestyle arrangement for people using the service reflected their preferences and how they wished to spend their day. The age range was between 37 to 74 years of age. A number of people remained in the home pursuing their personal interests whist others were supported by staff to access resources in the local community. During a tour of the building and through informal discussions with people it was evident that a homely and relaxed approach to support and care was provided by staff. The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 13 Evening and week end arrangements also ensured people maintained contact with their local community and families. Two service users will regularly go home at the weekends and the remaining people receive visitors on a monthly basis. People are supported to access events and places of interest. This included events such as tag rugby, shopping trips, pub meals, and trips to Hulme Library or Wythenshawe forum and trips to the local cinema complex. People are supported to plan annual holidays; one group would be going on a planned holiday to Spain and another group going on an adventure week in Wales. People using the comment cards confirmed such events are held and people spoke about how they were supported on such events during informal discussions throughout this site visit. During the course of the visit a number of people living in the home were observed to be involved in domestic tasks. During discussions with people and from reading peoples files, it was evident that their involvement in such tasks was chosen by them and enabled people to maintain and develop their daily living skills in a safe and supported environment. People who attended resources outside of the home are also involved in educational and leisure activities, which enable them to further develop their skills and establish links with the local community. The manager also stated that one person was hoping to be start some work experience. Meals are prepared using a four-week rotating menu plan. Staff stated that the menu plan is reviewed to reflect seasonal variations. The menu plan offer alternatives and a menu board is used to detail the daily choices. It was positive to note the people living in the home are supported to be involved in food preparation arrangements with the support of staff. There were ample provisions available in the kitchen and storage areas, with evidence of fresh meat, fruit, milk and vegetables, purchased weekly or delivered on a daily basis. Some provisions are stored in a dry external facility where the laundry service is operated. The manager is advised to consult with environmental health section on this arrangement. Staff received appropriate training in basic food hygiene to support their responsibilities when preparing meals. The manager was advised to provide staff with paper hand towels in the kitchen as opposed to use of cotton towels. This is advised in terms of good practice and infection control procedures. The Boundary DS0000021605.V334544.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal and health care arrangements for people living in the home were appropriate to meeting their assessed care needs. Medication procedures protected people. EVIDENCE: The care plans of two people were examined along with a number of daily records relating to a wider group of people. The daily records were found to be informative and regularly contributed to by staff. Individual files contained a significant amount of information in relation to health and personal care needs. A number of documents are used to record specific information such as health appointments, weight records and records relating to risk assessments. People are encouraged to be as independent as possible in all aspects of daily living and personal care with support where assessed as required. Care plans The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 15 were being reviewed to ensure the support plan clearly set out the level of assistance and encouragement required for each individual. People living in the home continue to access health practices in the local community, with the support of their key worker. Designated staff oversee medication procedures. Medication is held securely and was found to be in order when examined on the day of the visit. There are appropriate procedures for recording medication received by the home and when returned to the chemist for disposal. The home uses the Venolink system, which provides medication in sealed blister pack form. The only comment related to the need for staff to ensure both initials are used on the medication administration records. The use of one initial may be mistaken as a code indicating medication was not administered. The procedures for handling keys were the responsibility of the designated person with responsibility for its administration, determined on a daily basis. Staff had received appropriate training in procedures relating to the administration of medication. The Boundary DS0000021605.V334544.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures relating to raising concerns or complaints and adult protection procedures were established and protected people using the service. EVIDENCE: The manager stated the home had not received any complaints in the period since the last inspection; a complaints, compliments and concerns register should be put in place for the home. The Commission had received no complaints in the same period. Ten people living in the home completed and returned comments cards and recorded on the forms that they were aware of whom they would speak to if they had a concern. The statement of purpose for the home clearly sets out the procedures people can follow to have concerns and complaints dealt with. The home had a copy of Manchester’s Local Authority policy on Protection of Vulnerable Adults from Abuse. The manager stated all staff had been given time to read the document and was advised to retain evidence through a signed tracking form competed and signed by all staff. The manager also confirmed all staff had received training in adult abuse protection and procedures to be followed in the event of a disclosure of abuse. This was provided in July 2004, with additional training planned in 2007. The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 17 The last key inspection report required the home to develop secure protection procedures relating to storage of peoples’ cash cards and PIN numbers. The manager stated that procedures have been reviewed and at present these are held securely off the premises. The manager is again advised to review this practice. Financial procedures were discussed and examined. Procedures on the day were found to be in order and protected people. The manager was advised to retain evidence that the manager or responsible individual on a regular basis conducts internal audits of records. The Boundary DS0000021605.V334544.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a homely, clean, well-maintained and safe environment. Some environmental issues required addressing to ensure people are safe at all times. EVIDENCE: A tour of the home was undertaken and was lead by one of the people living at the home. Permission had been sought from people to enter their room as part of the tour. The building and communal areas are well maintained, pleasantly decorated and homely. The lounges and dining areas are easily accessed and used regularly by people living in the home for social and leisure interests. Bedrooms, although some are small in size, were found to be personalised and reflected the varying interests of the people living in the home. The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 19 The building incorporates two semi detached properties. As a result there are two boilers servicing the property. The radiators and hot water feeds in the main communal area were excessively hot and required monitoring and regulating to ensure people were not placed at risk. The hot water feed in the bathroom was tested and gave a reading of 55 degree centigrade. Action must be taken to ensure temperatures are regulated to 44 degrees centigrade. The manager was also advised to ensure all doors to bathrooms and toilets had a functioning privacy lock. Bedroom doors should be fitted with appropriate locks where requested by people; one person had a small bolt fitted to the inside of their bedroom door. More appropriate locks such as turn thumb devices should be fitted. The bath fronting was broken and the shared sections presented as a risk to people using this facility. The fronting to the bath should be replaced. A caster on one bed was damaged and the manager was advised to have it repaired. The route from the back of the home down the side of the building is used for access and in the event of evacuation. The area should be kept free of hazards such as uneven surfaces, waste disposal bins and rusted metal post retainers. Action is required to address this issue. The manager described the procedure to address ongoing repairs and produced a recording system used to identify work required in the home. The Boundary DS0000021605.V334544.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures developed by the home had improved to ensure staff had the necessary support and training they require to meet people’s needs. EVIDENCE: The home had taken positive steps to address the development of supervision and training programmes for staff. The staff team is made up of the manager, a deputy, senior carerand five support workers. The manager and deputy continue to work in excess of 40 to 50 hours per week. The rotas for the home are planned using a 4 week rotating plan. The hours for each week will average out at 210 care hours. As on previous reports this figure includes the hours worked by the manager and deputy. The arrangements for cover at night are one person on waking duty and one other person, sleeping in but available in the event of an emergency. The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 21 During discussion with the manager she was advised to review this arrangement and to allocate specific hours to the management and development of administration procedures for the home. Staff files contained the information required by regulation to evidence recruitment, selection and staff development systems in the home. The manager had completed NVQ level 4 and the registered managers award in November 2006. The deputy manager had also achieved NVQ level 4 award. Training had been provided to staff on issues relating to medication, moving and handling, learning disability awareness and fire safety. Training is planned to cover such topics as challenging behaviour, continence management and whistle blowing procedures. The manger was advised to access abuse awareness training. Programmes of staff supervision and staff meetings had been established by the manager and deputy manager. Records were available to evidence that such sessions had started for staff. The Boundary DS0000021605.V334544.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management procedures ensure the home is operated in the best interest of people living there. EVIDENCE: Comments from people using the service on the day and in comment cards received prior to the inspection stated that people liked living in the home and were happy with the support and care offered by staff. As on previous inspections, the manager is advised to establish a positive balance between a hands on approach to care and developing management and administration procedures. The manager and deputy manager are advised to set aside designated hours specifically for office-based work to develop this aspect of the service. The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 23 The manager and deputy manager had the necessary qualifications and experience to run the home and have worked at the home for a number of years. Records relating to tests and checks on fire systems were well maintained. The manager and deputy manager stated that staff had recently received training in fire procedures. During discussion on the training received, concerns were raised by the inspector in relation to an outcome of the training, which indicated that evacuation should only be through doors which open outward. The concern being that only one exit route meets this suggested criteria. The home is advised to consult with Greater Manchester Fire Authority on this matter. Information on the pre inspection questionnaire indicated that officers from the above section and Environmental Health had not visited since 2001 and 2003 respectively. The most recent quality assurance survey of people views about the service was conducted in March 2006. The home is advised to repeat this exercise on a regular basis in order to evidence formal consultation with people about the services they receive. The Boundary DS0000021605.V334544.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 X 2 3 3 X 4 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X The Boundary DS0000021605.V334544.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 YA24 Regulation 23 Requirement The home is required to take action to address the following issues relating to the premises: Radiators and hot water feeds in the main communal area were excessively hot and required monitoring and regulating to ensure people were not placed at risk. Doors to bathrooms and toilets must have a functioning privacy lock. Bedroom doors must be fitted with appropriate locks where requested by people to maintain privacy. The bath fronting was broken and the shared sections presented as a risk to people using this facility. A caster on one bed was damaged and required repairing. To ensure the safety of the resident. The route from the back of the The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 26 Timescale for action 14/06/07 home must be kept free of hazards. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard YA5 YA6 Good Practice Recommendations The manager is advised to ensure that each person living in the home had a statement of the terms and conditions of their placement. All review forms should be dated to ensure the review process is held at regular intervals. It is recommended that the home continue with developing the new care planning system for all the people who live at the home. The manager is advised to ensure staff use both initials on the medication administration records. The use of one initial may be mistaken as a code indicating medication was not administered. It is advised that staff are provide with paper hand towels in the kitchen as opposed to use of cotton towels. This is advised in terms of good practice and infection control procedures. The manager is advised to retain evidence that staff have been given time to read Manchester adult protection guidelines. Procedures implemented in relating to storage and protection of people’s valuables should be reviewed. The manager was advised to retain evidence that internal audits are conducted in relation to finance records. The manager is advised to allocate specific hours to the management and development of administration procedures for the home The home is advised to consult with Greater Manchester Fire Authority and Environmental Health Section on fire and health and safety issues. The home is advised to ensure quality assurance surveys of peoples views about the service they received is held on a regular basis. 3 YA19 4 YA30 5 YA23 6 YA23 7 8 9 YA31 YA37 YA37 The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North West Regional Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Boundary DS0000021605.V334544.R01.S.doc Version 5.2 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!