Inspection on 19/02/07 for Upton Road (82)

This inspection was carried out on 19th February 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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Upton Road (82) 25/08/05

Upton Road (82) 23/02/05

Upton Road (82) 31/08/04

Upton Road (82) 27/02/04

Upton Road (82) 23/02/03

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 Upton Road (82) 82 Upton Road Moreton Wirral CH46 OSF Lead Inspector Inger Moynihan Key Unannounced Inspection 19th February 2007 09:30 Upton Road (82) DS0000018950.V294619.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 Upton Road (82) DS0000018950.V294619.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. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Upton Road (82) Address 82 Upton Road Moreton Wirral CH46 OSF 0151 604 1406 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) Alternative Futures Limited Linda Ann Glover Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th August 2005 Brief Description of the Service: 82 Upton Road is large detached house in Moreton on the Wirral. It provides accommodation, support and personal care to five younger people (18-65 years) that have a learning disability. All accommodation is provided in single bedrooms which service users are able to personalise with their own belongings. The home has a large lounge, dining room, walk in shower and assisted bathroom. There is one bedroom on the first floor and four bedrooms on the first floor. The home does not have a lift. The home has its own mini bus which enables service users to use community facilities without having to rely on public transport. There is a bus stop just outside the home. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information about 82 Upton Rd was obtained through discussion with the Registered Manager and members of the staff team. Supporting documentation was looked at along with a selection of service users case files. Staff and service users views were obtained through discussion and observation. A selection of their comments are included in the report and contribute to the basis of any judgments made. Fees: £1407.88p per week. What the service does well: Service users are only provided with a service after their needs are assessed and they have been assured these needs will be met. Service users are encouraged to make decisions and take risks as part of living an independent lifestyle. Service users are encouraged to pursue their own interests and hobbies within the local community, which gives them opportunity for their own personal development and the development of personal relationships. Personal support is offered to each service user in accordance with their own particular needs and to ensure their privacy and dignity is maintained. Service users health care needs are monitored and met to ensure their ongoing good health. The home has a complaint procedure to ensure service users views and concerns are listened to and acted upon. One of the service users spoken to during the visit said she was very happy living at the home and had no complaints to make. Systems are in place to ensure service users are protected from abuse, neglect and self harm. Service users are supported by competent and qualified staff. Staff of appropriately supervised and provided with a range of training to ensure they develop within their role and are up to date with current care practices. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 6 82 Upton Road is run for service users best interests with their health, safety and welfare being promoted. The quality assurance systems ensure the standard of the service is regularly monitored, reviewed and improved. The staff spoke highly of the Registered Manager and confirmed she was always available for support and advice. The staff spoken to during the visit confirmed Alternative Futures was a good organisation to work for and they felt well supported in their role. The Registered Manager spoke highly of the staff team and confirmed they were very flexible and hard-working. 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. Upton Road (82) DS0000018950.V294619.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 Upton Road (82) DS0000018950.V294619.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. Service users are only provided with a service after their needs are assessed and they have been assured these needs will be met. EVIDENCE: An assessment of service users care needs is carried out. Information about the service users care needs is obtained from relevant health care professionals to ensure staff have the information they need on how to provide an appropriate package of care. The staff spoken to during the visit confirmed they had access to this information. The Registered Manager recognised that the full range of issues relating to equality and diversity need to be further developed during the assessment process to ensure service users holistic care needs are assessed and met. The Registered Manager outlined how she was in the process of updating service users assessment information into a Person Centred Plan. This Person Centred Plan gives staff more detailed information about service users past experiences, particular likes and dislikes and future aspirations and personal development. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements need to be made to the documentation held about how service users care is provided. This will ensure staff have the information they need on how to look after the service users properly. Service users are encouraged to make decisions and take risks as part of living an independent lifestyle. EVIDENCE: A plan of the care provided to each service user has been documented to give staff the information they need on how to look after the service users properly. A lot of information is held on file in relation to service users past experiences, current care needs and future aspirations and in some respects it was difficult to establish the care being provided. However it is acknowledged this issue will be addressed by way of the new Person Centred Planning format being introduced into the home. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 10 Some service users present with challenging behaviour. Staff are trained on how to support and manage service users when they may become verbally or physically aggressive. Written guidance is also in place about how staff should support the service users with this aspect of care provision. While the Registered Manager stated that all of the care plans had been reviewed and updated, there was no evidence of this in some cases. Some documentation relating to staff interventions had not been signed or dated so it was not possible to establish the accuracy of the information. There was no evidence that health care professionals had been consulted on whether the agreed plan of care should continue. The Registered Manager acknowledged that more detailed information needs to be recorded during the review process to demonstrate the decisions made with regard to any changes to service users care plans. Service users are encouraged to make decisions about their lives in order to maintain an independent lifestyle. Staff demonstrated an understanding of how to ensure service users rights are promoted and how limitations are only put in place for their safety and welfare. The Registered Manager stated that independent advocates are consulted when necessary. Although service users are encouraged to take responsible risks, a range of risk assessments have been carried out to ensure they are protected from the risk of harm. The Registered Manager outlined how she is in the process of updating the risk assessments to ensure staff are clear on the action they must take to minimise the risk of harm. Staff have completed training in relation to risk assessment and how to keep themselves and the service users safe from harm. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 11 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. Service users are encouraged to pursue their own interests and hobbies within the local community. This gives them an opportunity for their own personal development and the development of personal relationships. EVIDENCE: None of the service users are currently in employment. Service users social care needs are assessed and a range of activities is provided inside and outside the home. This prevents the service users from becoming bored and ensures their mental stimulation and social interaction. These activities encourage service users to establish and maintain relationships for their own personal development. The activities are provided on an individual basis as well as in a group and include day trips out, picnics and pub lunches. Some service users attend day centres and social clubs in the evening. The home has its own minibus which means service users can get out and about very easily although Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 12 public transport is also used. Staff are making arrangements for service users to go on holiday in the summer. Last year service users went to Spain, Blackpool and Centre Parks. Service users dietary needs are assessed and met on an individual basis. Service users are offered a choice of meals which staff prepare. Some of the service users are involved in the menu planning and weekly shopping to ensure they have meals they enjoy. Staff also arrange for take-away meals to be provided as treats. Service users generally eat together although individual care needs are catered for when required. Special diets are catered for when necessary. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 13 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 support is offered to each service user in accordance with their particular needs and to ensure their privacy and dignity is maintained. Service users health care needs are monitored and met to ensure their ongoing good health. EVIDENCE: Staff outlined how they provide different levels of personal care to each of the service users and confirmed that a record of this information is kept in service users Personal Support Plan. Personal support is provided in private and by a person of the same gender where possible. This ensures service users privacy and dignity is maintained. Times for getting up and going to bed are flexible. The home has a walk-in shower and an assisted bath to promote service users safety. Service users physical and emotional health care needs are monitored and met with a record of any health care appointments being kept. Service users Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 14 receive regular health checks from their GP, dentist, optician and chiropodist. Service users are also offered annual healthcare checks. A member of staff reported that he is continuing to develop the service users communication records, as some service users communication is limited. Staff take responsibility for the administration of service users medication to ensure their health and welfare. Staff have been provided with training in relation to this aspect of care provision and arrangements are being made for further training to be provided later in the year. Staff spoken to during the visit confirmed they had access to supporting policies and procedures when necessary. A selection of medication administration record sheets was looked at during the visit. All of the information recorded on these record sheets was hand written. Under such circumstances two staff signatures must be obtained following completion of these record sheets to ensure the accuracy of the information. This issue was discussed with the Registered Manager who was advised to consult with the supplying pharmacist for the purpose of providing pre-printed medication administration record sheets. Some of the supporting documentation held in relation to the administration of medication on the basis of as a one required was not dated and the list of medication for individual service users was out of date. The Registered Manager agreed this information needs to be reviewed and changed. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 15 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. The home has a complaint procedure to ensure service users views and concerns are listened to and acted upon. Systems are in place to ensure service users are protected from abuse, neglect and self harm. EVIDENCE: The CSCI has not received any complaints about the standard of care provided at 82 Upton Road and no complaints had been made directly to the home. Discussion with staff confirmed they were aware of the action they should take in the event of a complaint being made and a documented complaint procedure is available for service users. One of the service users spoken to during the visit said she was very happy living at the home and had no complaints to make. The staff spoken to during the visit confirmed they have received training around the protection of vulnerable adults from abuse and knew what action to take in the event of them suspecting an incident of abuse had occurred. They demonstrated different levels of understanding of this aspect of care provision. A copy of the Wirral adult protection procedure was in place to ensure any allegations of abuse are dealt with correctly. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 16 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. For the most part the home is well maintained and provides a comfortable and homely environment of the service users to live. However, further work still needs to be carried out in some areas. EVIDENCE: The home is in keeping with the local community and provides a homely environment for the service users to live. All parts of the home are accessible to the service users as they are all mobile. The home does not have lift. On the day to visit the home was clean and tidy and comfortably warm. One service users bedroom was particularly cold. This issue was addressed during the visit when a member of staff explained that the heating had been turned off and would come back on again at 6 p.m. Given that some of the service users were spending the day at home and the weather was cold, the Registered Manager must ensure that an optimum temperature is maintained throughout the building at all times. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 17 Service users had personalised their bedrooms to reflect their own interests and hobbies. All bedroom doors have a lock which can be opened by staff in an emergency. Since the last visit the communal areas have been decorated which further improves the condition of the building. The following issues arose that require further attention: • • The floor covering in the bathroom on the first floor was very dirty The carpet in two bedrooms were badly stained It was reported by the Registered Manager that the stains on the bathroom and bedroom floors could not be removed. Although it is acknowledged that these carpets are not a risk to health and safety, they do not meet an acceptable standard in relation to providing service users with a pleasant and comfortable place to live. In the light of this, the Registered Person is required to replace these floor coverings to ensure a more homely environment is provided. Laundry facilities are sited away from the kitchen. Policies and procedures for control of infection are in place. Soiled laundry can be washed appropriately. Staff have completed training in relation to infection control. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 18 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 33 34 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff. More detailed information needs to be obtained about staff prior to them being employed to ensure they are suitable to work with vulnerable adults. Staff are appropriately supervised and provided with a range of training to ensure they develop within their role and are up to date with current care practices. EVIDENCE: Thorough staff recruitment procedures are in place. Alternative Futures is an equal opportunities employer and issues of equality and diversity are explicitly addressed during the interview process. The staff spoken to during the visit confirmed they have completed a Criminal Records Bureau check to ensure they are suitably to work with vulnerable adults. A record of this information is in place. Three staff records were looked at during the visit. Most of the Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 19 necessary information had been collated prior to the staff member being employed although the following information was outstanding: • • • No staff references were in place for one member of staff A photograph was not in place for two staff members A statement as to one staff members physical and mental health had not been obtained. The Registered Person is required to ensure all of the necessary information is in place in order to demonstrate that suitably qualified and competent staff are employed. The staff rota indicated there were between three and four staff on duty during the week and two staff on duty at the weekend. Although staff vacancies existed, these hours were being covered by the existing staff team and sometimes the homes own bank staff were used. The Registered Manager and staff confirmed there were sufficient staff on duty to look after the service users properly. The Registered Manager reported that the existing staff vacancies would be filled by the 3 March 2007. The Registered Manager reported that at no staff were being provided with one-to-one care staffing hours. Documentation is in place to demonstrate that staff have completed a range of appropriate training and a training programme for the forthcoming year is in place. This training covers a range of issues relating to the care and support of vulnerable adults and the efficient running of the home. The staff spoken to during the visit confirmed the organisation provided a lot of staff training which they were always encouraged to attend. Staff receive induction training when first employed. All of this is in line with good practice and ensures staff are up-to-date with changing care practice issues. The Registered Manager acknowledged the staff training records need to be updated and streamlined for the efficient running of the home and to demonstrate that suitably qualified staff are employed. Staff spoken to during the visit confirmed they receive regular supervision from the Registered Manager. They all confirmed this meeting was useful and gave them an opportunity to develop within their role. The staff spoke highly of the Registered Manager and confirmed she was always available for support and advice. The staff spoken to during the visit confirmed Alternative Futures was a good organisation to work for and they felt well supported in their role. The Registered Manager spoke highly of the staff team and confirmed they were very flexible and hard-working. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 20 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. 82 Upton Road is run for service users best interests with their health, safety and welfare being promoted. The quality assurance systems ensure the standard of the service is regularly monitored, reviewed and improved. EVIDENCE: The Registered Manager is qualified and experienced to manage the service which is run for the service users best interests. She is qualified to National Vocational Qualification level 4, which is the recognised qualification for a manager of a residential care service. Documentation is in place to confirm the Registered Manager has undertaken periodic training to update her knowledge and skills. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 21 Systems are in place to ensure the ongoing monitoring and improvement of the service provision. This includes supervising staff, reviewing administrative procedures and reviewing service users care packages to ensure they accurately reflect their current care requirements. A newsletter from the organisation is sent to service users family and health care professionals. An area manager and a manager from another Alternative Futures care service audit the homes systems and procedures regularly. During the visit the Registered Manager experienced some difficulty in locating information and she was not familiar with the National Minimum Standards for Younger Adults. The Registered Manager highlighted the difficulties she experienced in this aspect of the running of the home and agreed that she needed to improve her administrative systems by setting time aside for this work. She agreed to discuss this issue with her line manager in order to establish a more improved way of working. Alternative futures is an equal opportunities employer and policies are available around this aspect of care provision. These policies highlight the ethos of the organisation with regard to ensuring all staff are treated with respect. Systems are in place to ensure service users health, safety and welfare is promoted through staff training and supporting policies and procedures. Regular health and safety checks are carried out around the building to ensure both staff and service user safety. Merseyside Fire Service has recently inspected the home. It was reported that all fire safety procedures, supporting policies and procedures and risk assessments were in good order. Two issues arose as a result of this inspection which the Registered Manager stated she was in the process of addressing. Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 22 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 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 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 3 x x 3 x Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 23 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. 1 Standard YA2 Regulation 14 Requirement The Registered Person is required to ensure each service users Person Centred Plan is completed so that staff have the information they need on how to look after the service users properly. The Registered Person must ensure issues of equality and diversity are incorporated into the assessment process. The Registered Person is required to ensure all aspects of the service users care plan are signed and dated and that more detailed information is recorded during the review process. The Registered Person is required to ensure outstanding risk assessments are updated to ensure staff have the information they need on how to minimise the risk of accidents happening. The Registered Person is required to ensure all records relating to the administration of service users medication are accurately maintained. The Registered Person is required to ensure a comfortable and homely environment is DS0000018950.V294619.R01.S.doc Timescale for action 30/04/07 2 YA6 15 30/04/07 3 YA9 13 30/04/07 4 YA20 13 31/03/07 5 YA24 23 31/08/07 Upton Road (82) Version 5.2 Page 24 6 YA24 23 7 YA34 18 8 YA35 18 9 YA37 18 provided for the service users to live. In this instance the carpets in the bedrooms and the lino in the bathroom on the first floor are replaced. The Registered Person is required to ensure the home is kept comfortably warm throughout the day. The Registered Person is required to ensure all the necessary information is collated prior to a member of staff being employed. The Registered Person is required to ensure staff training records are updated to demonstrate that suitably qualified and competent staff are employed. The Registered Person is required to ensure the Registered Manager improves the administrative systems within the home. 19/02/07 19/02/07 30/04/07 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Upton Road (82) DS0000018950.V294619.R01.S.doc Version 5.2 Page 26 - 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!