CARE HOME ADULTS 18-65
The Grove 65/67 Belfield Digmoor Skelmersdale Lancashire WN8 9HQ Lead Inspector
Val Turley Unannounced Inspection 9th May 2007 9:45 The Grove DS0000005996.V334201.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 Grove DS0000005996.V334201.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 Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Grove Address 65/67 Belfield Digmoor Skelmersdale Lancashire WN8 9HQ 01695 725119 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) Dawaking Care Ltd Mrs Jean Maureen Connolly Care Home 7 Category(ies) of Learning disability (7) registration, with number of places The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. This home is registered for a maximum of 7 service users in the category of LD (Learning Disability) 16th March 2006 Date of last inspection Brief Description of the Service: The Grove is at the end of a terrace comprising of two properties in the Digmoor area of Skelmersdale. It provides long- term placements for seven adults with a learning disability. The home is well situated in relation to local shops and facilities. The home has been extended and provides single bedroom accommodation on three levels. There are two lounges, a dining room, kitchen and a laundry room. There is a bathroom on each floor. The home can provide accommodation for one person with a physical disability as it has a ground floor bedroom and a ground floor toilet and shower. The grounds of the home are paved with planted areas and provide ramped access to both the front and rear of the house. Fees at the home range from £400 - £2500 per week depending on the individual support needs of the people living at the home. There are additional charges for hairdressing, toiletries and leisure activities. The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an inspection that took place over a fourteen-month period and culminated in a site visit to the home over one day in May 2007 by one regulatory inspector. The inspection involved discussion with the people living at the home, discussion with staff, observation of staff supporting residents and an examination of records, policies and procedures. Information was also provided through a pre-inspection questionnaire completed by the provider, through surveys completed and returned by 6 of the residents, and 3 completed by relatives of people living at the home, 1 by an advocacy co-ordinator and 1 by a care manager. As part of the inspection, the inspector used ‘case tracking’ as a means of assessing some of the National Minimum Standards. This process enabled the inspector to focus on one of the people living at the home. Records relating to that individual were inspected and discussion took place with that person and other people who were present in the home on the day of the site visit. What the service does well:
The Grove has a clear view of how to best support the people living there. This begins even before they move into the home. The home works with the individual and any involved health and social care professionals to ensure as far as possible that the home is able to provide the support that each person needs. A care manager wrote that the home ‘are good at communicating with all professionals involved.’ Wherever possible people are encouraged to become involved in the development of their care plans and these are reviewed at least on a monthly basis to make sure that people receive the right support. Risk assessments were linked to the care plans. These are in place to help make sure that the people living at the home are kept as safe as possible when involved in activities both inside and outside the home. The home also works with the residents to help them to each develop a person centred plan. This process encourages and supports individuals to identify their likes and dislikes and any goals or ambitions they may have. The plans are very personal to each of the residents and are presented in ways that helps the residents to understand them more easily. One involved professional wrote in the survey that they completed that ‘the staff place person centred working high on their agenda.’
The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 6 The people living at the home are able to make decisions about the way the home is run and great efforts are made to ensure that they are able to make choices and decisions about their own lifestyles. Where this is not possible, advocates provide additional support for service users. The people living at the home are supported to get involved in a range of leisure and work activities including attendance at college and the use of leisure centres, local shops and pubs. Contact with families and friends is encouraged and visitors are made welcome in the home. The residents spoken to said they liked living at the home and liked the staff who worked there. One person living at the home wrote ‘everything is ok’. The home is generally clean and homely and there are plans to redecorate and replace some of the furniture in the near future. It provides a pleasant environment for both the people living at the home and the support staff working there. The residents are able to personalise their bedrooms to reflect their interests and hobbies. The staff respect the privacy of the residents and always knock before going into their room. The people living at the home are able to lock their bedroom doors if they are able to manage this. The residents decide their own menus and are able to take their personal likes and dislikes into account when doing this. The staff provide sensitive support at mealtimes, which are relaxed and unhurried. The home has good policies and procedures in place with regard to any concerns or complaints made about the home and these are made available in a format that the people living at the home are able to understand more easily. The staff team are carefully selected and recruited with all of the necessary checks being made to help make sure that people are kept safe. New staff feel well supported and the manager is seen to be both approachable and supportive of staff. The staff team as a whole have a good range of skills and qualifications and are knowledgeable about the needs of the service users. A range of training opportunities had been provided for them to help ensure that their skills were updated. The staff were seen to be sensitive in the support they offered residents and the residents were relaxed in their presence. In a survey completed by a family member, the relative wrote that her cousin ‘praises a lot of the staff at the home’. The registered manager of the home is experienced in her role. She is aware of the need to keep her skills updated and had attended a number of training courses. She has a good overview of the needs of the needs of the service users, the staff team and the home in general and benefits from a good support network within the company. The home has a number of quality assurance checks in place and these help to make sure that the home is run safely and with the best interests of the residents in mind. All systems and equipment are serviced and maintained appropriately. Staff receive training in health and safety issues and this is backed up by detailed policies and procedures in respect of health and safety issues.
The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
It was recommended that any hand written entries on the MAR sheets (medication administration records) should be checked and signed by two people to reduce the risk of any errors being made. As the staff at the home had no experience of reporting any allegations or concerns in respect of the people they supported, it was recommended that the staff team look at and discuss the policies and procedures that are in place to help ensure that they have a thorough understanding of their responsibilities. The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 8 It was recommended that the home fit a doorbell to the front door for the benefit of residents wishing to gain access to the home and also for visitors to the home. 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 Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 9 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 Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 10 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 excellent. This judgement has been made using available evidence including a visit to this service. The pre-admission process is in sufficient detail to ensure that prospective residents support needs are fully assessed before admission. EVIDENCE: The files of two people recently admitted to the home were examined. From the information available it was clear that the home had received an assessment of each persons individual support needs and this helped them to make a decision as to whether they could provide the support that each person needed. The home had also been provided with information from each person’s previous placement and this also helped the home to decide if the right support could be provided. Where it had been possible the person visited the home before they moved there and were involved in the decision to move there. Care plans were in place for each of these people and these were based on the support needs identified in the pre-admission period. Where possible the residents had signed their care plan to indicate that they were in agreement with it. The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 11 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 excellent. This judgement has been made using available evidence including a visit to this service. People were supported to take responsible risks based on good information and enabled them to work towards a more independent lifestyle. EVIDENCE: The file of the person whose care was tracked during the site visit contained a very detailed care plan and included information for staff as to how best to provide support on a daily basis and also how to manage some of the challenges the individual presented. The person had signed the plan to show that they agreed with it. To make sure that the care plans met the needs of the service users, they were reviewed whenever it was necessary and at least once a month by the staff and where possible with the service users. They were reviewed formally
The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 12 every six months and this review involved, if possible, other health and social care professionals involved in providing supporting to the individual residents. Risk assessments were linked to the care plans. These were in place to help make sure that the people were kept as safe as possible when involved in activities both inside and outside the home. The home encouraged people to make decisions and choices about their support needs and lifestyle. During the course of the visit to the home support staff were observed to ask people what they would like to do. An advocate was involved in the home and she worked with individual residents helping them to make decisions and choices or helping to making informed decisions on their behalf. The home also had a key worker system in place and they gave people living at the home individual support, helping them to make decisions and choices. Regular monthly meetings for the residents also provided opportunities to make decisions as to how the home was run. The home had introduced Person Centred Planning for the people living at the home. This process encouraged and supported people to identify their likes and dislikes and any goals or ambitions they may have. The plans were very personal to each of the residents and were presented in ways that they were able to understand them more easily. Since the previous inspection the staff team at the home had discussed the importance of security at the home and the importance of ensuring that residents who needed close supervision were not able to leave the home unescorted. There was evidence of this within the team meeting notes and those staff spoken to were aware of their responsibilities. The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 13 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 excellent. This judgement has been made using available evidence including a visit to this service. People were supported to take responsible risks based on good information and enabled them to work towards a more independent lifestyle. EVIDENCE: From evidence on peoples files and from discussion with both the people living at the home and support staff, it was clear that residents were supported to become involved in a range of activities that they as individuals valued. These included contact with family members attendance at college, swimming, singing at church, attendance at church, holidays, lunches out and supporting a favourite football team. People were also supported to make use of local facilities including shops, pubs and leisure centres. The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 14 During the course of the site visit to the home a relative called to visit one of the residents. The visitor was made to feel welcome and looked relaxed during their time at the home. The people living at the home were supported to personalise their bedrooms to reflect their hobbies and interests. There were locks on the bedroom doors and residents held keys to these if they wished to and if they could manage the use of keys. Staff were observed to knock on bedroom doors before entering the room. Residents had unrestricted access to all the communal parts of the house except the kitchen and this was kept locked for reasons of safety. The people living at the home met on a regular basis to discuss and decide on menus. Individual likes and dislikes were taken into account in the planning. Alternative meals were seen to be provided for people who had specific dietary needs. Mealtimes were relaxed and unhurried with help being given sensitively to those people who needed it. Each resident was weighed on a regular basis as a means of monitoring his or her general health and well being. The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The support staff had a good knowledge of each person’s preferences and personal care and health care needs and provided support sensitively and in accordance with their wishes. EVIDENCE: The care plans for each person living at the home outlined his or her specific health and personal care needs. The home had also developed health action plans for each person that helped to identify and manage any health concerns as well as maintain a record of routine health appointments. The home had reviewed the format of the health action plans and planned to introduce a new more person centred plan. Records showed that there was involvement of a number of health care professionals in the home. These included a physiotherapist, a behavioural nurse specialist and an occupational therapist. The residents were supported to
The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 16 attend GP and outpatient appointments and routine health screening appointments. The home had made considerable efforts to ensure that equipment and aids were provided for the benefit of both the residents and the staff. Alterations were also being made to one of the bedrooms to give the staff more room to attend to the personal care needs of one of the people living at the home. The support staff were aware of the individual residents preferred routines in terms of bed times, baths, meals etc and these details were included in both the care plans and in each persons person centred plan. Observation of the staff supporting the people living at the home and discussion with them showed that they had a good understanding of the support each individual needed and preferred. Medication within the home was well managed and the policies and procedures regarding the administration of medication had recently been updated and contained all the expected information and detail. A checklist for auditing the medication had also been developed and had just been introduced to the home. Any staff administering medication had received training. All of these measures helped to ensure that the medication in the home was managed and administered safely. One recommendation was made and that was that any hand written entries on the MAR sheets (medication administration records) should be checked and signed by two people to reduce the risk of any errors being made. The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 17 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 excellent. This judgement has been made using available evidence including a visit to this service. The home had good policies and procedures in place in order to protect service users. EVIDENCE: The home had detailed policies and procedures in place in order to protect the people living at the home as far as possible. Staff received training in the protection of vulnerable adults and the residents and those relatives who completed the survey said that they knew how to make a complaint. The homes complaints policy and safeguarding of vulnerable adults policy had also been given to the people living at the home in a format that they would find easier to understand and this was also displayed within the home. As the staff at the home had no experience of reporting any allegations or concerns in respect of the people they supported, it was recommended that the staff team look at and discuss the policies and procedures that are in place to help ensure that they have a thorough understanding of their responsibilities. Strategies were in place to manage any challenging behaviour presented by the residents and the home involved relevant health and social care professionals to provide additional guidance and support. The homes approach was strengthened by policies and procedures that worked towards protecting both residents and staff.
The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 18 The home had clear policies and procedures in place in terms of supporting people to manage their finances as safely as possible. During the course of the site visit, staff were observed accessing the residents monies and following the procedures by signing for the money and obtaining receipts for purchases made. The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, homely and with the accommodation available being used for the benefit of the people living there. EVIDENCE: On the day of the site visit to the home, work was being undertaken to improve the facilities in the bedroom of one of the people who lived there, giving them easier access and provide more room to enable a hoist to be used more easily. In connection with this work a second person had moved to a different bedroom. Inevitably this work had left the home untidy and a little disorganised, however the people who lived at the home who were directly affected by this work were accepting of it and understood how they would benefit.
The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 20 The rest of the home was clean, tidy and homely. Bedrooms were personalised and reflected the interests of the people they belonged to. The proprietor of the home was present during the inspection. He said that there were plans to redecorate the home once the alterations had been completed and that some of the furniture was to be replaced. One person was heard to discuss the redecoration plans with a member of staff and choose the colour that they wished their bedroom to be painted. It was recommended that the home fit a doorbell to the front door for the benefit of visitors to the home. The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, and 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home selects and trains staff appropriately to ensure that people living at the home receive the support that they need. EVIDENCE: During the site visit the file of a recently appointed member of staff was examined. The file showed that the home had followed all of its procedures and all of the necessary checks and references were in place before the member of staff started to work in the home. The member of staff confirmed that these checks had been undertaken. The member of staff concerned said that the support that was provided by the manager and staff team was very good and had been very useful in the settling in period. The staff team as a whole had a good range of skills and qualifications. A range of training opportunities had been provided for them and staff had either signed up to or had achieved a nationally recognised qualification in care. Staff were given opportunities within supervision to discuss their professional
The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 22 development and additional training was planned to broaden the skills base of the staff team. The staff team met every 1-2 months when they were given opportunities to discuss any concerns or ideas that they may have about the way in which the home was run and also to discuss any specific issues in relation to the individual residents. During the site visit the residents were observed to be relaxed in the company of the staff and were able to ask for help or support. The staff on duty were sensitive in their approach and enthusiastic about their work. It was clear that they had a good knowledge of the residents support needs and respected their individual needs and preferences. The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed, providing a safe and relevant service for the service users. EVIDENCE: The registered manager of the home was experienced in her role and had achieved a NVQ level 4 in care and management. She was aware of the need to keep her skills updated and had attended a team leading course and undertaken refresher training in all the mandatory courses. The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 24 The manager had a good overview of the needs of the needs of the service users, the staff team and the home in general. The manager had a good support network. The proprietor of the home and the company’s general manager called in on a daily basis to provide support and guidance. She also had regular contact with other managers within the company providing each other with additional support. The home had a number of quality monitoring systems in place. There were regular internal checks on the homes documentation including care plans and risk assessments and also on the environment. These helped to ensure the safety and well being of both the people living at the home and the staff team. The homes policies and procedures were reviewed and updated as necessary to reflect any changes in legislation and good practice. The home had achieved the Investors in People Award which is quality assurance award accredited by an outside body. The home was also a member of the British Quality Foundation, which provides support to businesses enabling them to improve their performance. The home undertook annual surveys of the views of the people living at the home, their families and friends and any involved professionals. The residents survey had been produced in a format that they could understand more easily. The most recent survey undertaken in December 2006 had not highlighted any major criticisms although an action plan had been put into place to address any concerns. The residents met every 1-2 months and were given opportunities to influence the way the home was run. There was evidence that the home was run as safely as possible with all systems and equipment being serviced and maintained appropriately. Staff received training in health and safety issues and this was backed up by detailed policies and procedures in respect of health and safety issues. Accidents and incidents were recorded in such a way that the manager could identify any patterns or emerging trends The Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 25 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 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 Grove DS0000005996.V334201.R01.S.doc Version 5.2 Page 26 No 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. Standard Regulation Requirement Timescale for action 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 YA20 YA23 Good Practice Recommendations Hand written entries on the MAR sheets (medication administration records) should be checked and signed by two people to reduce the risk of any errors being made. The staff team should look at and discuss the policies and procedures that are in place in respect of concerns complaints and protection, to help ensure that they have a thorough understanding of their responsibilities. The home should fit a doorbell to the front door for the benefit of residents wishing to gain access and for visitors to the home. 3 YA24 The Grove DS0000005996.V334201.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 Grove DS0000005996.V334201.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!
