Care Home: Haddon House

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What the care home does well The new Haddon House provided very good facilities and comfortable, attractive, accommodation for the people using the service. There was a good way of finding out about peoples` abilities, needs, likes and dislikes before using the service. A checklist was being used to make sure any changes were known about before people came back to Haddon. People staying at Haddon House were being involved with different activities and were getting out into the community. People were being involved as much as they were able, in making decisions about how they spend their time. Help with personal needs was being given with care and people were being treated with respect. The staff team were enthusiastic and keen to provide a good service. To promote peoples` rights and choices, efforts had been made to help keep people informed, by including pictures on menus and important instructions. What has improved since the last inspection? This was the first inspection following registration of the service. What the care home could do better: Individual Plans for people using the service needed further details; to make sure staff know exactly what to do for each person and how to treat them. Improvements were needed with some medication matters; to make sure people are properly and safely supported. To make sure Haddon House is properly run, a senior person needed to be on duty at all times to share management responsibility. To make sure Haddon House is being properly run for the benefit of people using the service, a senior manager needed to carry out surprise visits and report on their findings. So people using the service can be supported to keep things private and safe, lockable storage should be provided in bedrooms. CARE HOME ADULTS 18-65 Haddon House Greenock Street Burnley BB11 4DT Lead Inspector Mr Jeff Pearson Unannounced Inspection 17th October 2007 09:15 Haddon House DS0000070342.V350512.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 Haddon House DS0000070342.V350512.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. Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haddon House Address Greenock Street Burnley BB11 4DT 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) 01282 454392 01282 454439 Lancashire County Council Mrs Kathleen Anne Brindle Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - code PC to people of either gender whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of people who can be accommodated is 6. Date of last inspection Brief Description of the Service: Haddon House provides a short break service for up to six people with a learning disability. The house, a purpose built establishment stands in its own grounds in a residential area quite close to the resources in Burnley town centre. There is a car park to the front of the building, with paved and lawned areas with raised flowerbeds to the rear. The home is all on one level, therefore making it accessible to all people using the service. There are two lounge areas and a conservatory offer a good choice of communal areas. All 6 bedrooms are single with en-suite facilities. Two of the bedrooms also share an assisted bathroom with tracking hoists, which lead from the bedroom into the bathroom. All bedroom room sizes exceed the National Minimum Standards. An additional assisted communal bathroom is available. There are suitable, sufficient specialist equipment in place to meet people’s needs. Staff are available to provide personal care and support in response to individual needs and abilities. At the time of the inspection visit the charge to stay at Haddon House was £9.55 per night. Service users were expected to pay for or contribute to, the cost of outings and some outside activities. Information about the service, including the service user guide, statement of purpose and previous inspection reports, was available on request. Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Haddon House on the 17th October 2007. The visit took 9½ hours and was carried out over one day by one inspector. Prior to the site visit, the registered manager was required to complete and returned to the Commission an Annual Quality Assurance Assessment (AQAA). This was to enable the service to show how they were performing and provided details about arrangements, practices and procedures in the home. The residents and their relatives were invited to complete surveys, to tell the Commission what they think about the care service provide at Haddon House, however none were received at the Commission. The files/records of two people using the service were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people using the service. Some discussion took place with people using the service, support and care practices were observed. The acting manager and staff on duty were spoken with. Various documents, including policies, procedures and records were looked at. The accommodation and facilities were viewed. At the time of this inspection visit there were 2 people using in the service. What the service does well: The new Haddon House provided very good facilities and comfortable, attractive, accommodation for the people using the service. There was a good way of finding out about peoples’ abilities, needs, likes and dislikes before using the service. A checklist was being used to make sure any changes were known about before people came back to Haddon. People staying at Haddon House were being involved with different activities and were getting out into the community. People were being involved as much as they were able, in making decisions about how they spend their time. Help with personal needs was being given with care and people were being treated with respect. The staff team were enthusiastic and keen to provide a good service. Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 6 To promote peoples’ rights and choices, efforts had been made to help keep people informed, by including pictures on menus and important instructions. 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. Haddon House DS0000070342.V350512.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 Haddon House DS0000070342.V350512.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. The admission process ensured peoples’ needs and aspirations were known and planned, for before they used the service. EVIDENCE: The service users case files seen, included assessment information from Social Services. Assessments had also been completed as part of ‘key contact’ arrangements, which involved details being gathered about peoples’ individual needs and abilities prior using Haddon House. Various matters had been considered such as health needs, medication, personal care, diet, finances, getting out and about and relationships. Parents and carers were being involved as appropriate. A keyworker system was in place which involved staff working more closely with individual service users, part of the role was to liaise with people and their families prior to using Haddon House and on return visits. Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 9 Staff spoken with explained how they were involved in finding out about people, building relationships and establishing contacts prior to service users coming into Haddon House and prior to returning. The AQAA (Annual Quality Assurance Assessment) completed by the manager, indicated that plans were being made to hold intake meetings with various people, such as families and staff from other services, to share information and help ease the admission process. The acting manager explained that progress was being made, to introduce a smoother transition for people using children’s services to the short break service. The service user guide was unable to found, however, a draft copy of ‘An Introduction To Haddon House’ was seen, this provided an insight into what people can expect from Haddon House and included pictures and symbols which may be useful for some people with a learning disability. Haddon House DS0000070342.V350512.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): 6,7,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The care planning process aimed to ensure peoples individual needs, abilities and choices were properly responded to. EVIDENCE: The service had a newly revised and updated care plan format. However, the acting manager was considering further developments to ensure needs were fully identified and responded to. The care plans for two service users were looked at. These showed that their personal, health and social support needs had been noted, with more detailed instructions for staff to follow. Where people had Person Centred Plans devised in other services, these were being shared more readily with staff at Haddon House. The information then being used; to supplement individual plans at Haddon House. Staff spoken with explained that peoples’ care plans were developed over time when they returned to the service. Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 11 The AQAA (Annual Quality Assurance Assessment) completed by the manager and discussion with staff showed care plans were being reviewed more regularly with the involvement of others. Plans were being routinely reviewed an updated when people returned to Haddon House. People using Haddon House were observed to be sensitively involved in activities of daily living; for example, they were consulted about day to day matters such as meals, drinks, TV programmes, music choices and other matters which affected them. The care planning process helped ensure their individual needs and wishes were known and planned for. Any limitations on choices had been identified and agreed prior to using the service. Risk assessments were seen to have been completed in response to individual abilities, including behavioural and mobility needs. Risk assessments were discussed with staff on duty. In particular, ensuring all aspects of safety are fully considered and balanced with promoting independence and choice. General risk assessments had been completed in relation to some health and safety matters, such as service users accessing the kitchen and laundry areas. The AQAA identified involving parents and carers in care planning and risk management strategies, as a plan for future improvement. Haddon House DS0000070342.V350512.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): 12,13,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People using the service were being offered opportunities to engage in a range of activities, they were supported to use community resources. EVIDENCE: People staying at Haddon House are supported to continue attendance at schools, day centres and colleges during their short stay break. People from various cultural backgrounds are often accommodated; individual needs are responded to accordingly. A ‘things to remember’ prompt sheet goes out to people before they return to the service. Staff spoken with explained that they were just getting to know about the various recourses and leisure facilities in the area. A file had been put together on local community resources this was being updated. Daily diary notes showed peoples participation in activities and outings. Staff spoke of the Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 13 various activities, both in and out of the home, including, pubs, shops, day trips, cinema and leisure centres. There had been two recent outings to Blackpool. Various games were available, including computer games, colouring books sand a karaoke machine. Televisions had been provided in bedrooms. The raised flowerbeds provide opportunity for gardening skills. The acting manager said sensory equipment had been ordered. Staff spoken with said they aimed to provide for individual needs and preferences, which also including supporting people to have some ‘quiet time’. People were seen to have freedom of movement in the building; they could make use of their own rooms and other areas, there were some restrictions for health and safety reasons. One member of staff had produced a picture version of the fire procedures, which to be displayed around the building. Records showed people’s relationship needs were being considered; service users were being supported to keep in touch with families and others as appropriate. Compatibility of occupants was being considered when arranging stays at the service. Policies were available to provide guidance on approaches to personal relationships. Individual food likes and dislikes were known, specific diets for cultural, heath and religious needs were being catered for. Mealtimes were flexible, depending what was happening and who was being accommodated. Choices were being offered; a pictorial version of the meals on offer was displayed in the dining room. A dietician had been consulted to provide support with devising menus. People using the service were seen to be asked for their choice of meal at teatime. Haddon House DS0000070342.V350512.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): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Most health and personal care practices and procedures were effective in ensuring people’s needs are properly and safely met. EVIDENCE: Personal support and health care needs were included in individual care plans. The acting manager agreed, more specific details would ensure clearer instructions are given to staff to promote continuity of care. Details of peoples’ personal support and health needs were being obtained from parents and carers, as appropriate. Where available, copies of people’s health care action plans had been obtained. Staff had received training in relation to specific health care matters such as epilepsy. Support would be provided as needed for any medical appointments. Staff spoken with said the level of support needed could influence getting up times; discussion took place about finding a balance between personal choice Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 15 and duty of care. They expressed very sensitive approaches to providing personal care, promoting dignity and privacy at a practical level. The accommodation at Haddon House promoted privacy and dignity, all the bedrooms were single with lockable doors, all had en-suite facilities. There was suitable equipment to assist with mobility needs. Medication policies and procedures for the short break service were seen to be available. Medication storage facilities were satisfactory. All staff had received guidance and training in administration of medication. Records seen were mostly clear and up to date; but there were some gaps in the MAR (medication administration records) looked at. The systems and practices for medication leaving Haddon House with people attending day centres was not clear. One item of topical medication did not have clear instructions as to ‘where’ on the body it was to be applied, although staff were aware of the instructions for its use. There was no list of staff signatures against initials for identification purposes, the acting manager agreed to ensure a list is kept. Haddon House DS0000070342.V350512.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): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Policies, procedures and practices were effective in supporting the complaints process, and in safeguarding the people using the service. EVIDENCE: The complaints records were unable to be located, however, the AQAA (Annual Quality Assurance Assessment) completed by the registered manager, indicated that complaints about the service had reduced radically and that the minimal complaints had been dealt with quickly and efficiently. There were various formats available, to provide guidance for people on making a complaint. Lancashire County Council, Social Services had produced a complaints procedure with pictures and symbols. There was also a ‘draft’‘ copy of Haddon Houses’ own five step complaints procedure, which included pictures. A ‘making a complaint’ booklet was also available, it was noted the Commissions contact details needed updating to include the correct information. Since the last inspection, staff had received POVA (Protection Of Vulnerable Adults) training; some training had also been given on dealing with aggressive behaviours and conflict. Policies and procedure were available relating to the protection of vulnerable adults. A ‘flow chart’ explaining the action to be taken Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 17 in response to allegations and incidents of abuse had been devised. Staff spoken with expressed a good understanding of safeguarding matters, including procedures for reporting bad practice. Haddon House DS0000070342.V350512.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): 24,30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The accommodation, facilities and equipment, provided a very well maintained and comfortable living environment for people using the service. EVIDENCE: The property was newly built, located in a residential area. The accommodation was on one level, therefore making it accessible to all people using the service. There were two lounge areas and a conservatory offering a good choice of communal areas, which were well equipped and furnished to a very good standard. The kitchen was well equipped and attractively finished. There were are office areas in the home, for storage of files, meetings and staff interviews. Suitable, sufficient specialist equipment in place to meet people’s needs, including tracking hoists. Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 19 There was much evidence of attention detail of décor, with coordinating fabrics, floor coverings and accessories such as pictures and cushions. Careful consideration had also been given to safety matters, with furniture being secured as appropriate. Bedrooms were of a partially high standard, spacious, well equipped and furnished. There were no lockable facilities in bedrooms; the provision of such storage, to support privacy and independence, was discussed with the acting manager. The building was found to be very clean and free from unpleasant odours. The laundry was suitably equipped and decorated. It was advised liquid soap and paper towels be provided in the laundry area. The acting manager confirmed cleaning staff were soon to be employed. Staff spoken with, said people using the service very much appreciated the new building and facilities, and that this had improved staff team morale. Haddon House DS0000070342.V350512.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): Quality in this outcome area is adequate 32,33,35 This judgement has been made using available evidence including a visit to this service. The staffing arrangements were satisfactory in providing people using the service with effective and consistent support. EVIDENCE: Positive and sensitive interactions were observed between people using the service and staff. The staff spoken with were enthusiastic and knowledgeable about their role in providing effective support for the various individuals using the service. Staffing rotas were being devised flexibly, to take into account the needs, abilities and routines of the people being accommodated. The rota showed various work patterns, influenced by the service users activities and support needs. The acting manager was aware that staffing levels would need ongoing review and attention, in response to peoples’ needs and abilities. Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 21 Shift leaders had been appointed the acting manager said their role was still being clarified. The staffing arrangements in place, did not properly provide for leadership responsibilities of Haddon House, in the absence of the manager and shift leaders. There were times when two support workers were on duty but neither had designated responsibility. Therefore, it was not clear who would take a lead in decision making process, for example, when the on call manager may be needed. The AQAA (Annual Quality Assurance Assessment) indicated ‘in house’ staff training had been held. Staff spoken with said training, supervision and staff meetings were ongoing, records were available of meetings held. Four support workers had attained NVQ (National Vocational Qualifications) Level 2 or above. New staff were said to have completed LDAF (Learning Disability Award Framework) training. Staff recruitment records were unable to be located, however, previous inspections of the Short Break Service have shown appropriate recruitment practices are carried out. One staff member spoken with explained the recruitment and selection practices carried out, including an interview, various checks and induction training. Haddon House DS0000070342.V350512.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): 37,39,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Most management and administration practices were effective in ensuring the home is run for the benefit of people using the service, staff and visitors. EVIDENCE: The registered manager was not on duty at the time of the visit to the service. However, she had recently been registered with the Commission and information available indicated Mrs Brindle was very experienced and had obtained several relevant qualifications in social care, management and Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 23 training. It was also apparent, she had put much effort into ensuring a smooth transition to the new Haddon House. The acting manager in charge was enthusiastic, proactive and competent within her role. But, due to her short time at Haddon House was not fully aware of all aspects of management and administration. Discussion took place about the need for the Commission to be notified in writing of the management arrangements in place, should the registered manager be absent for more than four weeks. Some quality assurance had been carried out, people using the service and their main carers had been encouraged to complete satisfaction surveys. It was advised the information from surveys be collated in the AQAA (annual quality assurance assessment) People were also being invited to comment on their stay following each visit. The Short Break Service had previously attained Investors In People accreditation and Charter Mark status. The AQAA showed several relevant policies and procedures were yet to be to be devised and introduced. The Commission had not received reports following monthly visits by representatives of the organisation, no such reports were available at Haddon House, these matter therefore needed attention. Arrangements were in place for staff to receive training in safe working practice subjects. All maintence records and installation certificates had been seen as part of registration processes. Systems were in place to record and follow up any heath and safety matters. The service had comprehensive health and safety policies and procedures in place. The acting manager had made arrangements for a health and safety officer to visit to advise upon on health and safety risk assessments. Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 X 3 X 3 X X 3 X Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 YA20 Regulation 13 (2) Requirement To make sure people using the service are properly supported with their medication, action must be taken to ensure appropriate administration records are kept. Appropriate systems must be introduced to account for medication leaving the home with service users. To make sure people using the service are effectively and safely supported, staffing arrangements must ensure a suitably competent and trained person is at all times on duty, to undertake management responsibilities. To make sure the home is being properly run for the benefit of service users, arrangements must be made for unannounced inspection visits to be carried out with findings being reported upon, in accordance with the requirements of this regulation. Timescale for action 30/11/07 2. YA33 18(a) 31/01/08 3. YA39 26(2) 31/12/07 Haddon House DS0000070342.V350512.R01.S.doc Version 5.2 Page 26 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 YA6 Good Practice Recommendations To ensure people using the service receive appropriate person centred support and care, all health, personal and social care needs should be detailed in their individual care plans. To ensure management of medication is safe and appropriate, the auditing system should include a more thorough check of all aspects, including records, storage and administration. To promote ongoing opportunity for privacy and security of possessions, along with independence skills, lockable facilities should be provided in all bedrooms. Copies of the reports completed in accordance with the requirements of regulation 26, should be retained at the home and made available at the next inspection visit. 2. YA20 3. 4. YA26 YA39 Haddon House DS0000070342.V350512.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. 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