Care Home: 59 Whitehorse Road

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What the care home does well Thorough assessment of people living in the service provided comprehensive care plans to ensure that people`s needs were catered for effectively. There was a positive emphasis focused on encouraging people to be involved in the development of their care plan.The service has developed a good quality assurance system covering a wide range of aspects relating to the management of the service which takes into account the views of people who live there , relatives and other health care professionals. What has improved since the last inspection? There was a marked improvement with information contained within care plans and a better emphasis focused on people participating in areas relating to their lifestyle, welfare and the general running of the home. CARE HOME ADULTS 18-65 Whitehorse Road, 59 59 Whitehorse Road Brownhills Walsall West Midlands WS8 7PE Lead Inspector Dawn Dillion Key Unannounced Inspection 14th March 2008 10:20 Whitehorse Road, 59 DS0000038819.V360275.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 Whitehorse Road, 59 DS0000038819.V360275.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. Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitehorse Road, 59 Address 59 Whitehorse Road Brownhills Walsall West Midlands WS8 7PE 01543 361478 01543 378407 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Jacqueline Anne Bernard Dorothy Jones Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2007 Brief Description of the Service: 59 Whitehorse Road is located on the outskirts of Brownhills, West Midlands. It provides a residential service for younger adults who have a learning disability. The service is accessible via public transport and close to local amenities. It comprises of six single occupancy bedrooms. En suite rooms are not provided. Bathrooms and toilets are in close proximity to bedrooms and communal areas. The service provides a large lounge come dining room. People living in the home have access to a domestic style kitchen and a separate laundry. The home has ramps and grab rails making it easily accessible. Staffing is provided on a 24-hour basis to ensure the total support and supervision of people living in the home. The fees chargeable for the service and provisions provided by the service were not identified on the Service User Guide. The reader may wish to contact the home directly for this information. Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is a 2 star. This means the people who use this service experience good quality outcomes. This unannounced Key Inspection of 59 Whitehorse Road was undertaken within seven hours. The inspection methodologies that were used to establish the quality of care provided and the effectiveness of the management of the home, to promote equality, diversity and best practices entailed the examination of the records, relating to the homes policies and procedures. People who use the service had very limited communication skills and it was difficult for us to engage in conversation with the individual, general observations during the process of the inspection provided evidence of peoples general routine within the home and their general welfare. One member of staff was interviewed and passing conversations with other staff provided a view regarding the quality of the service delivery. We looked at parts of the premises to ensure that the environment and systems in operation were safe and suitable to meet the needs of the people living within the service. What the service does well: Thorough assessment of people living in the service provided comprehensive care plans to ensure that people’s needs were catered for effectively. There was a positive emphasis focused on encouraging people to be involved in the development of their care plan. Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 6 The service has developed a good quality assurance system covering a wide range of aspects relating to the management of the service which takes into account the views of people who live there , relatives and other health care professionals. 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. Whitehorse Road, 59 DS0000038819.V360275.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 Whitehorse Road, 59 DS0000038819.V360275.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): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may wish to use the service are provided with some information to assist them in making a decision to whether the service would be suitable to cater for their assessed needs. EVIDENCE: Discussions with the registered manager confirmed that no one had been admitted to the service in recent years. The service did have a Statement of Purpose which provided information relating to the service and provisions available, to enable people wishing to access the service to establish if the home would be suitable to meet their assessed needs and to promote their health and welfare. The Service User Guide needs to be reviewed to ensure that the terms and conditions in respect of the accommodation and the amount and method of Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 9 payments are identified within this document so that people are fully aware of the cost of their placement. Some information was in place to provide people with detail about the service but this information was not published in a format to promote the understanding of people using the service. Our discussions with the registered manager confirmed that for any future admissions to the service, individuals would be subject to a needs assessment to ascertain the service’s capacity to meet the person’s care needs to promote their wellbeing. The Statement of Purpose identified that the service’s admission procedure includes a trial visit to enable the individual to establish whether they wish to live at the service. Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who access the service are able to make decisions about their lives and can participate in the planning of their care to promote their health, welfare and independence. EVIDENCE: People who use the service have complex care needs and some have limited communication skills. We looked at two care plans both provided in depth information relating to the individuals care needs and the level of support and assistance required to promote the persons health and general welfare. For example, one person who had limited communication skills, records evidenced the appropriate method of communication for this person. Discussions with Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 11 the registered manager confirmed that staff had received communication training such as Makaton. The registered manager confirmed that where possible people were actively involved in the development of their plan of care, some care plans has people’s signatures on them to evidence this. The care plans provided comprehensive information relating to the care needs, general wellbeing, the individual’s goals, aspiration and social stimulation to ensure that people are able to live a fulfilled lifestyle to reflect their individuality. Care plans provided information relating to the level of support the individual required to enable them to make decisions. For example, one care plan identified what was most important in one person’s life, such as maintaining contact with their family and going to the shops to buy a magazine. Discussions with the registered manager and the examination of records evidenced that regular meetings are undertaken with people who use the service. Minutes of meetings identified discussions relating to menus, key workers, staffing, holidays and social activities. The minutes identified people’s gestures and body language to confirm their understanding of what was discussed. We told the manager that consideration should be given in publishing minutes of meetings in a format to promote the understanding of people who use the service. One person living at the service has a communication book providing information relating to their daily routines and events of the day, to ensure the consistency with the delivery of care. Care plans included risk assessments identifying potential hazards and provided relevant information with regards to control measures, to promote the safety and independence of people who used the service. Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to make choices about their lifestyle and to learn new skills to ensure that they have a fulfilled and meaningful life. EVIDENCE: A number of people living at the service have limited communication skills. We observed staff interacting with people in a positive and professional manner, it was clear that they recognised and understood each individual’s needs with regards to body language and gestures. The registered manager informed us that one person was in paid employment at Clarity Gazebo and also attended a youth club during the week. Another person attended college undertaking a computer course to learn new skills. Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 13 People living at the service are able to access leisure services within their local community with the assistance of staff, for example going on shopping trips, to restaurants and social clubs. We saw that care plans provide information relating to the support people require to maintain contact with their family and friends, for instance staff provide escort to one person to enable her to travel some distance to visit her mother. Another person informed us that she was going home that day and was waiting for her father to arrive. We observed the daily routine to be relaxed, people have freedom of movement throughout. General observations and discussions with staff members confirmed that there is a positive emphasis focused on encouraging people to participate in the running of the home and in areas affecting their lifestyle, for example we observed staff asking people what they would like to do with regards to activities, such as watching the television, art and craft or reading a magazine. One person enjoys listening to music and spends sometime in his bedroom doing so. The service operates a four- week menu. Discussions with the registered manager confirmed that no special diets are needed with regards to cultural, religious or health needs. Although the menu provides an alternative choice it was not varied for example, Monday’s meal was fish, peas and potatoes or fish and chips. Wednesday beef stew or beef pie. The registered manager informed us that she was in the process of introducing new menus to provide more choice. We observed people having their evening meal, the atmosphere was simulating, with staff being attentive to support people to eat their meals. Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs, which promotes their wellbeing. The attitude of staff and care practices promote respect, dignity and privacy of people who access the service. EVIDENCE: We looked at two care plans all provided detailed information relating to the care needs of the individual and the level of support and assistance required to promote their independence, to ensure that they were able to live a lifestyle of their choice. We saw that care plans identified the intervention of other healthcare professionals such as a Psychologist and a Community Nurse. Discussions with the registered manager and information contained within care plans evidenced Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 15 that people using the service are offered the option of an annual health check to promote the individual’s general health and wellbeing. Our inspection of the services medication system identified that practices were thorough to ensure that people receive their prescribed medication as directed by the General Practitioner. The dispensing Pharmacist undertook an inspection of the homes medication system and practices on 01/02/08 following which no recommendations had to be made. Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure but this could be improved upon if produced in an appropriate format to aid people’s understanding People who use the service are guaranteed some element of protection with regards to the homes recruitment practices. EVIDENCE: The homes complaint procedure was located in the office; information relating to the complaint procedure was also identified in the Statement of Purpose. We looked at the complaint procedure, which identified that contact details on this document were out of date with regards to us The Commission for Social Care Inspection. Due to peoples’ limited communication skills, we were unable to get people to tell us who they would talk to if they were not happy. A complaints procedure was in place but improvement would be made if it was published in a format to promote the understanding of people who used the service. The manager told us that ‘people living in the home did not have their own copy of the complaints procedure because they would not understand it’. Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 17 Consideration should be given in reviewing the complaint procedure to ensure that it is functional to meet the needs of people who use the service. We have not received any concerns, complaints or allegation about 59 Whitehorse Road. The examination of the homes records identified that one complaint has been received from a neighbour raising concerns about parking of staff vehicles. Discussions with the manager confirmed that after liaising with the local Police, there was no issue of illegal parking. The registered manager told us that staff had not received safeguarding training and that she was waiting for funding to commission this training. We looked at two files pertaining to people who worked at the service to ascertain the recruitment practices. Both files evidenced that the appropriate safety checks had been undertaken, to promote the protection of people using the service The registered person should ensure that where convictions or cautions have been identified on a Criminal Records Bureau, a risk assessment should be put in place to ensure the protection of people living in the home. Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the service enables people to live in a safe, well maintained and comfortable environment which promotes their safety and welfare. EVIDENCE: 59 Whitehorse Road is located in a residential area of Brownhills, West Midlands. The single storey property comprises of six bedrooms. En- suite facilities are not provided but washbasins are installed in each bedroom. Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 19 All bedrooms are equipped with essential furnishings and fitments to promote the comfort of people living within the service. Although locking devices are not fitted to bedroom doors, staff were observed to knock on doors prior to entering the bedrooms. We saw that the lighting in one bedroom was poor due to the fact that two light bulbs were not working. The registered person should replace these to ensure the welfare and comfort of the person occupying this room. Bathrooms and toilet areas are in close proximity to bedrooms and communal areas. One bathroom is equipped with an assisted bath, to assist individuals with reduced mobility. There was no other specialist aids available within the home. However, this was not required for the current needs of people living in the home. Records evidenced that water temperatures within the two bathrooms are being monitored; this should be expanded to all areas to which people living in at the service have access, to ensure that people are not exposed to extreme temperatures. The service provides a large lounge come dining area, equipped with essential furnishings. People living at the service have access to a domestic style kitchen, a separate laundry area was also provided. Ramps and grab rails were also in place to assist individuals who have limited mobility. A large patio garden located at the rear of the property is accessible to people with nice views of neighbouring fields. Limited car parking is available at the front of the property. The general cleanliness within the service is of a good standard. Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who access the service benefit from an established staff team to promote their welfare and independence. The lack of emphasis focused staff training may have a negative impact on the quality on of the service delivery to ensure people’s needs are catered for appropriately. EVIDENCE: 59 Whitehorse Road provides care to six people. We examined the staff rotas to see if adequate staffing levels are being provided to cater for peoples assessed needs. Rotas did not give a clear indication of staff working patterns. For instance the rota identified that one staff member had commenced work at 8.30am with another staff starting work at 9.00am which indicates that one Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 21 staff worked alone for 30 minutes. The registered manager informed us that both staff did commence their duties at 8.30am. The registered manager should ensure that rotas provide accurate information to demonstrate that people who use the service are provided with the relevant support and assistance to ensure their safety and welfare. The registered manager informed us that all but one staff had obtained the National Vocational Qualification Level 2 or 3 in Care and that the other staff member had been registered to undertake the training. The examination of training records and discussions with staff identified that there was a lack of emphasis focused on staff training and development however it is positive that Staff received training relating to the Safe Handling of Medication in February 2007 and on the day of our inspection, in house training was being delivered relating to fire safety and first aid. The registered manager informed us that she was waiting for funding for further staff training, such as moving and handling, food and hygiene and safeguarding. This is necessary as some people who used the service did have limited mobility, all staff assisted with the preparation and cooking of meals and due to the mental capacity of people living in the home and their general vulnerability, adult protection training would be valuable. As previously identified within the contents of this report, we looked at two staff files that evidenced that the appropriate safety checks were undertaken to ensure the protection of people that accessed the service. Discussions with staff confirmed that they received regular supervision, providing the necessary support and guidance with regards to their roles and responsibilities to promote the quality of the service delivery. One staff member told us that, “The management support is brilliant, we could not ask for more.” Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect to promote the rights of people who access the service. People living within the service benefit from a quality assurance system that promotes the quality of the service delivery to ensure peoples’ assessed needs are catered for and to guarantee their general welfare and safety. EVIDENCE: Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 23 The registered manager is experienced within social care and has obtained the necessary qualifications pertaining to her roles and responsibilities. We were pleased to find that all requirements identified within the previous inspection report have been addressed within the timescale as this makes sure that people who use the service are better protected. We found a marked improvement with assessments and care planning, to ensure that peoples’ care and physical needs were catered for appropriately. Although we were not able to engage in conversation with people who use the service, general observations would suggest that people were comfortable and safe within their environment. People observed have freedom of movement throughout the service. The service operates a quality assurance system, for example reports are maintained within the service confirming that the registered provider undertakes monthly visits, to monitor the quality of the service delivery. During these visits where possible she engages in conversation with people who use the service to ensure that they are contented with the service provided. The quality assurance system also incorporates risk assessments regarding health and safety, smoking, finances amongst others. Quality Assurance questionnaires were distributed to people that used the service, families and professional agencies; the following comments were identified on the questionnaires: “Happy with the care routine.” “Happy with the quality of care.” “Happy with the home and the service provided.” “Staff always seems friendly and willing to answer any questions that may arise.” A letter from a Community Nurse stated, “The service users always appear well looked after and well catered for.” The quality assurance system also includes a “Service User Yearly Progress Development Plan.” The plan identified people’s progress in achieving their aims as identified within their care plan. The plan included information relating to decision-making, participation, education, religion, and community links amongst others. Our records identified that a request for an Annual Assessment Quality Assurance Assessment (AQAA) had been sent to the home. The AQAA is a Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 24 self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. We were informed by the service that they received this request but they mislaid the form. With reference to systems and practices that promote the health, safety and welfare of people accessing the service, records identified that routine safety checks were undertaken of appliances and fire fighting equipment to ensure the safety of all people who live at the service. Whitehorse Road, 59 DS0000038819.V360275.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 2 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 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 3 3 3 X 3 X 3 X X 3 X Whitehorse Road, 59 DS0000038819.V360275.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. 1. Standard YA39 Regulation Requirement Timescale for action 01/08/08 24(1)(2)(3) The registered person should take the necessary measures to ensure that the AQAA is completed, to demonstrate that the home has a consistent approach in maintaining quality standards as it is a legal requirement that this document is completed and returned when we ask this to be done. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations To ensure that the Service User Guide provides relevant information relating to the fees charged for the service and provisions, and that this document is published in a format that promotes the understanding of people who use the service. The menus should be reviewed to provide a wider range of meals. To ensure that people living in home have access to a DS0000038819.V360275.R01.S.doc Version 5.2 Page 27 2. 3. YA17 YA22 Whitehorse Road, 59 4. 5. 6. 7. 8. YA23 YA24 YA24 YA33 YA35 complaint procedure published in a format to promote the individuals understanding. To promote the safety of people living in the home, where Criminal Record Bureau checks identify convictions or cautions, a risk assessment should be put in place. To ensure that light bulbs in the identified bedroom is replaced. The monitoring of water distribution temperatures should be expanded to all areas where people living in the home have access. Staff working rotas should provide accurate information relating to the hours staff have actually worked. To ensure that all staff receive training relevant to their respective roles and responsibilities. Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Whitehorse Road, 59 DS0000038819.V360275.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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