Inspection on 28/06/07 for The Bungalow

This inspection was carried out on 28th June 2007.

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

Other inspections for this house

The Bungalow 23/02/06

The Bungalow 06/12/05

The Bungalow 12/11/04

The Bungalow 14/04/04

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 Bungalow 121 Worden Lane Leyland Preston Lancashire PR25 3BD Lead Inspector Mrs Lynn Mitton Unannounced Inspection 28th June 2007 10:00 The Bungalow DS0000040741.V337202.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 Bungalow DS0000040741.V337202.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 Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Bungalow Address 121 Worden Lane Leyland Preston Lancashire PR25 3BD 01772 457585 01772 434973 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) Social Services Directorate Mrs Julie Ray Care Home 4 Category(ies) of Learning disability (4) registration, with number of places The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home is registered for a maximum of four service users to include: Up to 4 service users in the category LD - Learning Disability. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 23rd February 2006 Date of last inspection Brief Description of the Service: The Bungalow is situated in a residential area of Leyland close to the town centre and associated facilities. It offers respite care for up to 4 younger adults with a learning disability and some additional physical disabilities. The Bungalow offers a friendly, domestic environment and is maintained to a good standard throughout. Accommodation is in single bedrooms, with lounge areas, dining area, and adequate bathroom and toilet facilities. The grounds are open and spacious with ramped access for the benefit of people using the service. People who use the service are encouraged and supported to become involved in community-based activities. The cost of a stay at The Bungalow is £9.55 per night. Information about the service they could expect was available to potential users. The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted on 28th June 2007. The registered manager completed a pre inspection questionnaire. The inspector visited 2 people using the service, and spoke to the support staff on duty at the time of the inspection. The inspector was advised that the registered manager was taking a number of months off from her post and that a manager from another short stay service nearby to The Bungalow was managing both services until the registered manager’s return. Throughout the report there are references to the “tracking process”, this is a method whereby the inspector focuses on a small representative group of people using the service. Records regarding these people were inspected. Two people were case tracked, their files examined in detail and two support staff member’s files were also case tracked. One of the Commissions surveys for service users was returned. One of the Commissions relatives/next of kin surveys was also returned. Comments and findings of these surveys are referred to in this report. The inspector conducted the inspection with the acting manager, as the registered manager is on leave of absence for 6 months. During the inspection a number of records, policies and procedures were also viewed. What the service does well: When asked on the Commissions survey “What do you feel the service does well?” one person’s relative wrote: “The Bungalow has provided a good service for my daughter in a friendly environment. She is always keen to go and enjoys each visit. The Bungalow provides a valuable service for our daughter and also all the family”. Every effort was made to support people to access the facilities in the local community although these opportunities were at times restricted by the lack of available transport, and not all people could use the transport. The Bungalow was run to make sure that people had opportunities to enjoy their stay and to fulfil their potential. People were able to make day-to-day decisions about their lives. Individual dietary needs were catered for. The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 6 Personal support was offered in a way that promoted empowerment, choice, dignity, respect and autonomy. The standard of décor, furnishings, cleanliness and hygiene provided a comfortable and homely environment for people using the service. Staff spoken to and observed by the inspector demonstrated a good understanding of the needs of the people. What has improved since the last inspection? What they could do better: The admission procedure for new people using the service should ensure that all information about their care needs was obtained before they arrived for a stay. This is so that staff have a clear understanding of what they needed to do for people. All people using the service should be issued with a contract, which outlines the responsibilities of both parties. The care and health needs of people using the service must be clearly identified and well documented. This would meant that needs would be met in a consistent manner. Risk assessments and management frameworks must be in place to enable people using the service to take responsible risks. Minor amendments would ensure good practice was in place with regards to the administration, safekeeping, storage and disposal of people’s medication. Complaints and protection policies and practices must be available to staff or people using the service. Only 14 of care staff had obtained their NVQ3 training to enable them to better meet the needs of people using the service. The required documentation to confirm the ‘fitness’ of the staff working at the home to work with vulnerable adults must be kept on the premises. The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 7 There was insufficient evidence to demonstrate that the registered person and the Commission were being kept informed about the running of the home. The views of people using the service and visitors about the running of the home had not been formally sought. Health and safety issues were not routinely checked and maintained in order to safeguard the health and safety of the people using the service and staff team. 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 Bungalow DS0000040741.V337202.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 The Bungalow DS0000040741.V337202.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. JUDGEMENT – we looked at outcomes for the following standard(s): YA2 YA5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment procedure did not always ensure that staff had a clear understanding of all of the needs of people coming to use the service. EVIDENCE: One person’s relative wrote: “we are contacted prior to each visit to arrange a time for admission to see if needs have changed”. Before staying at The Bungalow, information packs were completed by people using the service or their next of kin. Support staff also attended an intake meeting. However, needs assessments were not completed by support staff prior to people’s admission. The inspector saw contracts explaining the terms and conditions of service users stay at The Bungalow. However, of the three looked at, one contained out of date information, there was no evidence that one person had been issued with one, and only one was fully completed with this years costings. The Bungalow DS0000040741.V337202.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): YA6, YA7 & YA9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care needs of people using the service were not clearly identified or well documented. Risk assessments and management frameworks were not always in place to enable people using the service to take considered risks. EVIDENCE: Three care plans were examined during the inspection. These contained basic information about each person, but did not include a plan of action of how to address people’s specific needs. The inspector advised that care plans should give good detail of each person’s specific support needs and how the care staff team should meet these. The inspector was advised that a new care plan format was due to be introduced to The Bungalow in the near future, and that this format would incorporate the information needed. The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 11 Some of the daily records seen were unreadable, as carbon copies were made and the top copy sent home with the people using the service. The inspector advised that if this practice should continue then the carbon copy must be sent home, not the top copy. The inspector was satisfied that following discussions with staff people using the service were given information and options to help them make positive decisions about their own lives. Prior to each admission the staff at the home made enquiries as to whether the support needs of the person had changed at all. The inspector advised that risk assessments should be an integral element of the care plan, however, not all risk assessment were individualised, some were generic. Each risk assessment should include a management strategy. Risk assessments had been recently reviewed. The Bungalow DS0000040741.V337202.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): YA12, YA13, YA15, YA16 & YA17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Every effort was made to support people to access the facilities in the local community. The Bungalow was run to make sure that people staying there had opportunities to enjoy their stay and to fulfil their potential. They were able to make day-to-day decisions about their lives and their dietary needs were catered for. EVIDENCE: Since the previous inspection the inspector was advised that The Bungalow now had access to a vehicle for 5 people every other month. The vehicle was not suitable for wheelchair users, and this situation did restrict the possibilities of involving all the people using the service as a group. There was evidence however that people were supported to access the local community. For example, opposite the home is a large park and this has golf, arts centre a maze and a café. Whilst The Bungalow had access to the vehicle the inspector was advised that people went bowling, visited the cinema, went swimming, to The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 13 local pubs and for meals out. On Thursday evening, some people attended the local Gateway club. Records of activities undertaken were made on people’s daily records. Most people continued to attend their day care centre during the day whilst staying at The Bungalow. Family and friends may visit The Bungalow at any reasonable time, although usually families maintained contact by phone. The inspector spoke to the staff member on duty about how people using the service would be treat with dignity and respect. A record was made of meals served to people. The inspector advised that these should be recorded individually, not in one book. Menus were decided on a daily basis, dependent on the people staying at the home and their preferences. Any specialised dietary requirements would be accommodated, this included use of halal meat, pork free, diabetic and soft diets. The Bungalow did not employ a cook. Care staff prepare meals and service users were encouraged to participate in the shopping, preparation and planning of meals to the best of their ability. Staff were ready to offer assistance with eating where necessary, discreetly, sensitively, and individually. Adapted cutlery/crockery was available for those who need it. The Bungalow DS0000040741.V337202.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): YA18, YA18 & YA20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal support was offered in a way that promoted empowerment, choice, dignity, respect and autonomy. People’s health needs were not being recorded clearly or in sufficient detail to ensure they were met in a consistent manner. EVIDENCE: Care staff encouraged people using the service to be as independent as possible regarding their personal care. Some people needed prompting and others needed full assistance with their care needs. Information regarding the personal support each person required was not always recorded in sufficient detail on the current care plan information. One member of staff spoken to gave good examples of how they would promote a persons privacy and dignity whilst giving personal care. People case tracked had limited health information recorded on the present care plan. The inspector was advised that the new care plan format due to be introduced included medical history, medication, pain assessment, continence, nutrition, sleep, and communication information. The inspector advised that it The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 15 should be ensured that the health care plans contain information identifying people’s health needs and how these needs will be met. Policies and practices dated Feb 2006, for managing and administering medication in short break services was not seen in place. The person case tracked had their medication administered by the district nursing team; however, one medication had not been kept refrigerated. A detailed care plan was in place for one person’s specialist medication administration. Consent for administration of medication was seen on people’s files. Administration records seen were completed correctly. The inspector advised that a photograph attached to the outside of the MAR sheet would be much clearer than the photocopied version. A medication fridge was in place, and room temperatures were recorded daily. As no training matrix was available, the inspector was not able to establish if all care staff had undertaken training to ensure that they administered medication safely. Medications for people staying at The Bungalow were seen and these were clearly labelled by the dispensing pharmacist. Although the medication administration records were handwritten, they were seen signed by 2 members of staff on administration. The Bungalow DS0000040741.V337202.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): YA22 & YA23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints and protection policies and practices were not available to staff or people using the service. Staff training had been undertaken to ensure that all staff were familiar with abuse procedures and protection of vulnerable adults. EVIDENCE: There had been one complaint made to the home since the last inspection, however there was no evidence of how this complaint had been dealt with. The complaints policy and procedure was not available. The inspector advised that all staff should have access to these documents and sign to say they have read and understood policies such as these. There were comments/complaints forms by the front door of The Bungalow welcoming comments from people using the service. The inspector did not see evidence of the complaints procedure, which had been made available on video and DVD. The inspector was advised that there had been no allegations of abuse since the previous inspection. The protection of vulnerable adults guidance for staff could not be located. A whistle blowing policy was seen dated July 2005. The self-assessment document returned to the commission, advised that the staff team had undertaken protection of vulnerable adults training. The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 17 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): YA24 & YA30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of décor, furnishings, cleanliness and hygiene provided a comfortable and homely environment for people using the service. EVIDENCE: The furnishings and fittings were compatible with the needs of the people using the service and the purpose of the home as a respite/short stay facility. The Bungalow was spacious, clean and tidy, well decorated and furnished in a domestic style for the comfort of users of the service. There were no offensive odours. The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 18 Adaptations and specialist equipment was in place to meet the needs of people using the service, for example, there was specialist bathing facilities in place, en suite to one bedroom. Suitable laundry facilities were available. A large secure garden was available at the rear of the property for people using the service to enjoy. The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 19 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): YA32, YA34, YA35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Only 14 of care staff had obtained their NVQ3 training to enable them to better meet the needs of people using the service. Staff had a good understanding of the needs of the people using the service. EVIDENCE: The inspector noted that 1 out of 7 care staff had now completing their NVQ level 3 training. One member of staff was undertaking this training. At the time of the inspection there were 60 hours care staff vacancies. These were being covered by casual staff and the existing staff team doing extra hours. The staff files at The Bungalow did not however hold all of the documentation required to indicate that the necessary checks had been undertaken to confirm their fitness to work at the home. For example, the 2 members of staff case tracked did not have application forms, references, or photographs. The The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 20 manager stated that these documents were held within the Social Services Directorate Human Resources Department. Arrangements should be made to transfer the required documentation to the home. The inspector advised that as this issued had been outstanding since December 2005 high priority should be given. There was some evidence made available to the inspector on the day to demonstrate that care staff had undertaken recent training, and that regular 1:1 support meetings took place between the manager and individual staff members, but not that monthly team meetings took place. The inspector noted that the self-assessment document completed by the registered manager indicated that regular supervision meetings, team meetings and staff training did take place. Of the 2 members of staff case tracked there was an individual training record in place for one member of staff, this showed that some training had been undertaken recently, and that some health and safety training was outstanding, for example, food hygiene and 1st Aid. The inspector was advised that the other member of staff case tracked had recently completed LDAF Induction and foundation training. The inspector advised that a matrix containing all staff names with completed training would ensure that outstanding training could be identified. The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 21 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): YA37, YA39 & YA42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Bungalow was managed by a competent and experienced manager. The views of people using the service and significant others about the running of the home had not been formally sought. Some aspects of the management of health and safety did not fully safeguard the people using the service and staff team. EVIDENCE: The inspector was advised that the registered manager was taking a number of months off from her post and that a manager from another short stay service nearby to The Bungalow was managing both services until the registered The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 22 manager’s return. The inspector advised that the Commission should have been notified in writing of this. The home had achieved the Investors in People Award which is a quality assurance award accredited by an outside body. The home had also achieved the Chartermark Standard for Customer Service Excellence. Staff were in regular contact with families and received feedback from them regarding the service they provided which they were able to act upon. No formal surveys of peoples views of the service had been undertaken since 2004 and neither had the views of involved health and social care professionals, however, a carers meeting had taken place in May 2007 and a “Service users forum” meeting had taken place in April 2007, and minutes of these meetings were seen. The inspector was advised that a LCC district development officer was currently looking at the Quality Assurance process although this would not be specific to The Bungalow. The registered person’s representative was not regularly visiting the home to make sure that it was being run properly. So far in 2007, there had been 3 reports produced to the Commission. Records regarding the prevention of fire, and routine maintenance records of the gas and electrical supplies and appliances were seen and not all were found to be in good order. For example, records showed that the bath hoist had not been serviced since June 2006, the fire alarm had not been tested since April 4th 2007, and the last fire drill since November 1st 2006. Staff fire awareness training had not been completed since December 2005, however staff files seen indicated that this may not be the case. As there was no staff training matrix, it was difficult to establish if staff training had been undertaken with regards to ensuring the complete health, safety and welfare of service users and staff, for example in 1st Aid, administration of medication, COSHH and Fire Awareness. The inspector advised that bookings for the respite service should be made in pen once they have been confirmed to ensure accuracy and avoid potential error. The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 X 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 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X X 2 X The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 24 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 14, 19 Requirement The service user plan must reflect the care to be provided, they must be up to date and subject to regular review. There must be arrangements in place, such as risk assessments to ensure that people using the service and workers are so far as is practicable free from avoidable risks. The registered manager must ensure and provide evidence that the staff team have received training in the management and administration of medication. Medication requiring refrigeration, must be stored correctly. Complaint policies and practices must be in place and available to all. Evidence must be available to demonstrate that all complaints made are dealt with effectively, timely and in accordance with policies. Policies and procedures Timescale for action 02/11/07 2 YA9 13 (6) 02/11/07 3 YA20 13(2) 02/11/07 4 YA22 22 & Schedule 4 (11) 02/11/07 5. YA23 13(6) 02/11/07 Page 25 The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 6. YA34 7 YA37 regarding the protection of people using the service must be in place, up to date and available to all. 19(1)(b)Schedule The registered manager 2 must ensure that all of the required documents in respect of each member of staff employed are held at the home. (This requirement outstanding since inspection report dated 6/12/2005) 38 Where the registered manager proposes to be absent from the home for more than 28 days, the commission must be notified. 02/11/07 02/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8. 9 Refer to Standard YA2 YA5 YA6 YA17 YA18 YA32 YA35 YA39 YA39 Good Practice Recommendations A needs assessment should always be completed prior to people using the service. All people using the service should have a contract outlining the terms and conditions of the service they will receive and its cost. Care plans should be formally reviewed on at least a six monthly basis. Records of meals served should be recorded on each persons records. Personal care needs should be recorded in detail on each persons care plan. 50 of care staff should have achieved the NVQ 2 training qualification. Each members of staff should have an individual training profile and receive equal opportunities training. The home should seek the views of stakeholders on how the home is achieving goals for people using the service. The registered person or his representative should visit the DS0000040741.V337202.R01.S.doc Version 5.2 Page 26 The Bungalow 10 11 YA39 YA42 home unannounced and at least once a month. The registered person or his representative should visit the home unannounced and at least once a month. The registered persons should make arrangements for the training of staff in all area’s of health and safety The Bungalow DS0000040741.V337202.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Bungalow DS0000040741.V337202.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. 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