Latest Inspection
This is the latest available inspection report for this service, carried out on 17th September 2008. CSCI found this care home to be providing an Good service.
The inspector found no outstanding requirements from the previous inspection report,
but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.
For extracts, read the latest CQC inspection for The Boundary.
What the care home does well A committed team of support workers ensure people have access to a range of choices in terms of social and leisure interests. People living in the home confirmed they could access local resources and were supported by staff to do this. This included support with health care appointments. The support offered to individuals reflected their ability and preferences. Daily living arrangements are flexible and people can plan how they spend their day, when they get up and when they go to bed. People have unrestricted access to their own rooms.Work has started on developing plans of support to reflect people`s preferences. This involved the deputy and key workers working with individuals to record how they wished to be supported. Although there had been no admissions since the last inspection, clear procedures were in place to support people who may be considering moving to the home. People are encouraged to be actively involved in daily living arrangements from domestic to catering routines. During informal discussions with people living there they confirmed that the home met their health, personal and social interests. On the day of this visit there was evidence that people are encouraged to make choices about how they spend their day and have access to a number of community resources such as day centres, local amenities and leisure centres. It was evident that staff supported people to enable them to develop daily living skills, set objectives for the future and to maintain contact with family members and the community they live in. What has improved since the last inspection? Programmes of social care were established and promoted positive life experiences for people. There was evidence of ongoing programmes of decorating and maintenance to ensure a homely environment was established. The home had started reviewing records kept to evidence how people were being supported in a person centred way. Medication systems were organised and found to be in order. What the care home could do better: Risk assessments relating to the premises should be reviewed and monitored to ensure a safe environment is maintained. Issues identified in the environment section of this report identify areas to be addressed. The staffing levels at the time of the inspection appeared appropriate to meeting peoples needs. The overall hours continue to include the hours worked by the manager and deputy. It is recommended that the manager is allocatedadditional hours for the development of management and administration procedures. CARE HOME ADULTS 18-65
The Boundary 418 Parrswood Road East Didsbury Manchester M20 5GP Lead Inspector
Joe Kenny Unannounced Inspection 17 September 2008 09:30 The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Boundary Address 418 Parrswood Road East Didsbury Manchester M20 5GP 0161 445 0422 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 Teresa Williams Mrs Joan Elizabeth Ford Care Home 12 Category(ies) of Learning disability (12) registration, with number of places The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One named service user is aged 65 years or over. Should this service user leave the home the place will revert to the service user category Learning disability (LD). 19th April 2007 Date of last inspection Brief Description of the Service: The Boundary is a home providing accommodation and personal care for 12 adults with a learning disability. It is made up of two semi-detached houses converted into one to form a detached property. The home has a paved area at the front with parking for approximately three cars. The home also has a conservatory and a large rear garden with seating and shaded areas. The garage situated at the rear of the property is used for storage. Accommodation at The Boundary consists of eight single and two double bedrooms. There are two adjoining lounge areas, a kitchen and a large conservatory, which is used as a dining area and for activities. The home is situated in a residential area of West Didsbury, close to public transport routes into the city centre and surrounding areas. A railway station is less than five minutes walk from the home. The area has a good range of all the usual services, including shops, a post office and public houses etc. A large supermarket and a leisure park is situated less than five minutes walk from the home and there is a corner shop nearby, which is convenient for the people who live there. The Boundary DS0000021605.V364584.R02.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 2 star. This means the people who use this service experience good quality outcomes. The inspection of The Boundary was carried out unannounced on the 17 September 2008. The manager and deputy manager were available throughout the inspection. Information relating to people living there and documentation, such as, complaints, medication, staff rotas, training records and health and safety records were looked at as part of the inspection. Discussions were held with staff and people living there to seek their views about life in the home. The home provided the Commission with a completed Annual Quality Assurance Assessment (AQAA) which is a self-assessment of how it felt it was meeting national minimum standards. The inspection also looked at information received by the Commission in relation to the home prior to the site visit. A number of comment cards were forwarded to people living there and to staff as a further means of seeking their views. The home had taken steps to address requirements and recommendations made as a result of previous visits. A tour of the home and grounds was also undertaken. The fees for the home are £600.00 per week. What the service does well:
A committed team of support workers ensure people have access to a range of choices in terms of social and leisure interests. People living in the home confirmed they could access local resources and were supported by staff to do this. This included support with health care appointments. The support offered to individuals reflected their ability and preferences. Daily living arrangements are flexible and people can plan how they spend their day, when they get up and when they go to bed. People have unrestricted access to their own rooms. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 6 Work has started on developing plans of support to reflect people’s preferences. This involved the deputy and key workers working with individuals to record how they wished to be supported. Although there had been no admissions since the last inspection, clear procedures were in place to support people who may be considering moving to the home. People are encouraged to be actively involved in daily living arrangements from domestic to catering routines. During informal discussions with people living there they confirmed that the home met their health, personal and social interests. On the day of this visit there was evidence that people are encouraged to make choices about how they spend their day and have access to a number of community resources such as day centres, local amenities and leisure centres. It was evident that staff supported people to enable them to develop daily living skills, set objectives for the future and to maintain contact with family members and the community they live in. What has improved since the last inspection? What they could do better:
Risk assessments relating to the premises should be reviewed and monitored to ensure a safe environment is maintained. Issues identified in the environment section of this report identify areas to be addressed. The staffing levels at the time of the inspection appeared appropriate to meeting peoples needs. The overall hours continue to include the hours worked by the manager and deputy. It is recommended that the manager is allocated
The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 7 additional hours for the development of management and administration procedures. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures are in place to provide people with the information they need to make an informed choice as to where they live. EVIDENCE: There had been no new admissions or discharges for some considerable time. There were currently no vacancies in the home. The content of documents such as the statement of purpose and service users guide had not changed since the last inspection. It is recommended that a formal process of evidencing an annual review of such documents takes place. The main sections requiring updating on an annual basis would be information relation to staffing levels and staff training information. Procedures described by staff on how they would support people considering moving to the home were clear. Information about the home would be provided to the person considering moving and the manager of the service would conduct an assessment of the person’s needs. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 10 The assessment process had been reviewed to ensure the person being referred was consulted on their views about how they wished to be supported. This would be achieved by the introduction of person centred planning of care, to ensure peoples’ needs, gaols and aspirations are clearly assessed and identified before they come to live at the home. Information would also be received from the placing authority and the person would be offered the opportunity to visit the service to meet people living there and the staff. Visits to the home could be for a planned overnight stay or for the day. People would be offered the opportunity to have a meal and tour the building. People currently living there are supported to maintain contact with family members and friends. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support is provided to meet identified needs and plans were being reviewed to reflect any changes and risks to people. EVIDENCE: It was evident from discussions and observations that staff have a good understanding of people’s needs and have worked with people over a long period of time, supporting them in a positive and professional way. In order to ensure that staff’s knowledge, understanding of people’s needs and how people are supported is retained by the service there is a need to ensure records reflect and evidence the positive work being carried out at the home. The deputy manager had started the process of reviewing the content of care plans to progress towards person centred care planning. This should include The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 12 assessments of identified risks and specific issues relating to health, personal and social care. Daily records are maintained by staff and record events and activities which take place, including support offered to people by staff. Daily records for individuals were held collectively in a ring binder. The manager was advised to move records to the individual files of service users. People living in the home have opportunities to meet as a group to discuss issues relating to the operation of the home During discussion with senior staff and the manager it was again evident that time needed to be set aside to move the development of care plans on, as the manager and deputy continue to be very much hands on care. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The rights and choices of people are respected in relation to their chosen lifestyle within the home and their local community. Meal arrangements reflected people preferences. EVIDENCE: It was encouraging to note that throughout the inspection, there were no routines in the home and a relaxed and homely setting was evident in the way people went about their chosen activities. People confirmed they were free to plan how they spend their day and are supported and encouraged to establish and maintain contact with their friends, family and local community. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 14 People were observed to be involved in domestic routines such as doing their own laundry, making drinks and some light domestic duties. Some people went out on appointments and others remained in the home following their interests. Mealtimes were relaxed and offered people choice as to what they would like to have at the midday and evening meal. Staff consulted people on an individual and daily basis to determine what were their preferences at meal times and meals were prepared to reflect people’s choices. There were sufficient provisions in the kitchen and additional storage areas to ensure a range of choices could be offered to people. It is recommended that environmental health, are consulted on the suitability of storing food provisions in the external storage area. Provisions are purchased by contract/delivery and through use of local suppliers, ensuring fresh deliveries of daily essentials. People are encouraged and supported by staff to be involved in the purchasing and preparation of food. A record is maintained of meals provided. People continue to go on home visits and each person is supported by staff to plan an annual holiday. People spoke about how they had enjoyed their holiday this year; one group went to Jersey and another group went to Blackpool. At this time of the year people start to be consulted on where they would like to holiday in 2009 and plan and are supported to prepare for the trip. Some people are also involved in educational and leisure activities outside of the home, which enable them to further develop their skills and establish links with the local community. Information in the AQAA, “care programmes enable people to access social outing during the hours of 9am to 5pm at least twice a week, this can be shopping, pub lunches, coffee mornings, walking to local park, ten pin bowling/pictures or what even the client chooses to do where possible during the allocated time available”. The information in the AQAA identified a need to look at developing more activities in the evening and therefore a need to increase staffing to achieve this. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive the level of support they require in relation to their personal and health care needs. Medication procedures protected people. EVIDENCE: During discussion with staff they confirmed they were available to support people to varying degrees on health and personal care issues. The degrees of support varied based on each persons ability, with an emphasis on helping people to develop their personal skills and independence. Staff assisted people to arrange and attend health care appointments such as dentist and general practitioner appointments. Staff supporting people would attend the appointment to support people where they had requested such support. The records developed by the deputy manager, in terms of person centred planning were viewed and two files were looked at in more detail. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 16 The information maintained by staff as a daily record of how people were supported was found to be informative and regularly contributed to by staff. The files contained information from the time of the person’s admission, family and professional contact details and information in relation to health and personal care needs such as health appointments, weight records and records relating to risk assessments. People are encouraged to be as independent as possible in all aspects of daily living and personal care with support where assessed as required. Care plans were being reviewed to ensure the support plan clearly set out the level of assistance and encouragement required for each individual. Medication procedures were checked as part of the inspection and found to be in order and held securely. Staff, keep records of medication when delivered to the home and returned to the pharmacist for disposal. A team of designated staff are responsible for the administration and management of people medication. Medication is held in a secure facility within the office and on examination was found to be in order. The inspection included checking of medication records, audit of the blister system and audit of quantities of medication in table and liquid form. The home uses the Venolink system, which provides medication in a sealed blister pack. The procedures for handling keys to the system were the responsibility of the designated senior in duty each day. Staff had received appropriate training in procedures relating to the administration of medication. When people went on a recent trip their medication was taken with them and administered by staff supporting them. The medication administration records were signed ‘L’ for “leave”; the person dispensing the medication should have signed the records. . Procedures for when people go on home leave were in order as family members supported people on visits to their home address. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are aware of who to speak to if they have a concern about the service they receive. Policies and procedures are in place to protect people from harm or abuse. EVIDENCE: The manager stated the home had not received any complaints in the period since the last inspection. A complaints register is maintained and no complaints were recorded in the register. The Commission had received no complaints in the same period. The statement of purpose for the home clearly sets out the procedures people can follow to have concerns and complaints dealt with. To ensure people’s views are listened to, staff will meet regularly with people to discuss daily living issues and people living there have the opportunity to come together as a group to discuss topics relating to the running of the home. A brief information brochure is available for staff on Manchester’s Local Authority policy on Protection of Vulnerable Adults from Abuse. The manager stated all staff had been given time to read the document and was advised to retain evidence through a signed tracking form completed and signed by all staff.
The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 18 The manager was advised to access a copy of the fuller safeguarding guidelines. Monies held on behalf of service users was managed appropriately at the home. However, peoples’ bank account books were being held off the premises. Arrangements must be made for these to be retained securely at the home. Regular internal audits of finances should be carried out and in inventory kept of people’s belongings. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A homely, comfortable and well maintained environment is provided. EVIDENCE: The interior of the building and communal areas are well maintained, pleasantly decorated and homely. The lounges and dining areas are easily accessed and used regularly by people living in the home for social and leisure interests. Bedrooms, although small in size, were personalised and reflected the varying interests of the people living in the home. The heating for the building continues to be provided by two separate boilers and as on the previous visit the heating at the main building was found to be excessively hot and required monitoring and regulating to ensure people were not placed at risk.
The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 20 The route down the side to the building had been cleared to ensure the route out was not obstructed in the event of an emergency. Some pathways remain uneven and should be attended to, to minimise any risk to people using these pathways. Staff are available to support people and internal procedures are supported by regular health and safety checks and maintenance checks carried out by staff to ensure a safe environment is maintained. Areas which required attention, related to the following: It is advised that a paper towel dispenser is located in the staff toilet as part of infection control procedures as at present towels are used and staff are involved in caring and catering duties. The fence to the rear of the home needed attention to ensure it defined the boundary and offered security as a number of sections of fencing required replacing to restrict easy access onto the grounds of the property One out building was unsafe and could be accessed by users and required attention. Some cleaning solutions had been decanted into a secondary container; the container did not record the appropriate COSHH guidelines. Two mops and buckets were being kept outside the kitchen. Staff did appear to be aware of their use and were advised to have both clearly labelled. A container of prescribed cream was located in the kitchen and should be moved to the medication cabinet or the person’s bedroom. New PVC windows are in place in a number of rooms and required risk assessments to determine whether restrictors are needed. On touring bedrooms wardrobes required securing to the wall as they presented as risk to people in terms of them falling forward. The unit in one room, identified to the manager was deemed high risk and the manager agreed that it would be secured following the inspection. There was evidence of damp damage to the gable wall in room 3, which required rendering and redecorating. The manager was advised to have a glazing risk assessment carried out on the large panel in one bedroom as the panel was not shatter proof glass and may present as a risk to the service user. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment and selection procedures ensure people receive the support they require and are protected. EVIDENCE: The staff team consists of the manager, the deputy manager, senior carer and five care staff. The night hours are covered by two care staff on sleep in/on call duty, throughout the night. The staff rota for the period covering the inspection showed that a minimum of two staff were deployed throughout the day and night. Staff continue to be involved in domestic and catering arrangements as no designated ancillary staff are employed. The manager and deputy manager continue to provide hands on support to people living at the home. It is advised that management and care hours are The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 22 reviewed to allocate specific hours to the development of administration, policies and procedures for the home. The manager holds the files of staff and she confirmed that each person working at the home had the required checks and references taken up before starting employment. Informal discussions were held with members of staff and all confirmed they received induction and ongoing training appropriate to the work they do. All confirmed they received supervision on a monthly basis. Staff appeared very confidant, skilled and clearly got on well with all the people living at the home. Staff interacted well and were available to speak to people, support them and advise them on daily issues. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and administration procedures ensure the home is being run in the best interest of people who live there. EVIDENCE: The manager had the necessary qualifications and experience to manage the service. The deputy manager had also achieved NVQ level 4 award. During informal discussions with people living in the home they all said they liked living there and were happy with the support and care offered by staff. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 24 As previously stated, the manager is advised to establish a positive balance between hands on approach to care and developing management and administration procedures. Records relating to tests and checks on fire systems were well maintained. The deputy manager conducts tests and checks on the fire system and discussions were held with her on procedures relating to fire drills and testing of the fire alarm system. It was advised to designate a time and day of the week to carry out a test of sounders to ensure staff and people living there became familiar with the weekly tests and unannounced fire drills. Procedures relating to evacuation procedures had been discussed internally to ensure people were aware of the routes to be taken in the event of an emergency. The manager was advised to request an assessment of the service by environmental health care officers as no visit had been conducted to the home since 2003. Positive interactions and discussions were seen between staff and people using the service. It is advised that a formal consultation process is carried out annually through use of surveys to people living there, to establish quality assurance assessment systems and formal consultation with people about the services they receive. The staff team demonstrated a commitment to supporting and assisting people to achieve their aspirations and to make decisions and choices about life in the home and for their future. Other records relating to insurance liability, and health and safety procedures were checked and found to be in order. The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 X The Boundary DS0000021605.V364584.R02.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 YA24 Regulation 23 Requirement The home is required to take action to address the following issues relating to the premises: Radiators in the main communal area were excessively hot and required monitoring and regulating to ensure people were not placed at risk. Some pathways remain uneven and should be attended to, to minimise any risk to people using these pathways. All windows must be risk assessed and fitted with appropriate restraints if required. Free standing wardrobes presented as a risk to service users and should be secured to the wall. 2 YA23 17 In order to fully protect people. All financial information must be held securely at the home. 12/11/08 Timescale for action 12/11/08 The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA6 YA17 YA20 YA23 YA23 Good Practice Recommendations Daily records should be held in the main file as opposed to all records held in one ring binder. Advice should be sought from environmental health section in relation to storage of food provision in external buildings. Procedures for recording medication when people are on leave should be reviewed where staff continue to support people. Evidence should be retained that all staff have been given the time to read the Local Authority, adult safeguarding procedures. Procedures should be developed in relation to the storage of peoples’ valuables. An inventory of such valuables should be retained on site and evidence that regular internal audits of finance and valuables are conducted. Action should be taken to address the following; It is advised that a paper towel dispenser is located in the staff toilet as part of infection control procedures. The fence to the rear of the home needed attention to ensure it defined the boundary. One out building was unsafe and could be accessed by users requiring attention. Cleaning solutions should be retained in the original container. Mops and buckets should be clearly labelled in terms of their area for use. Prescribed cream should be held in the person’s room or in the medication cabinet. Damp damage in room 3, required rendering and redecorating. A glazing risk assessment should be carried out in the
The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 28 6 YA24 7 YA32 identified bedroom. It is advised that management and care hours are reviewed to allocate specific hours to the development of administration, policies and procedures for the home. It was advised to designate a time and day of the week to carry out a test of sounders to ensure staff and people living there became familiar with the weekly tests and unannounced fire drills. The home is advised to consult with Greater Manchester Environmental Health regarding the storage of food in an external area. The home is advised to ensure quality assurance surveys of people’s views about the service are maintained on an annual basis. 8 YA37 9 YA37 10 YA37 The Boundary DS0000021605.V364584.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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
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