Inspection on 03/08/06 for 13-15 Constitution Hill

This inspection was carried out on 3rd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

13-15 Constitution Hill 23/01/09

13-15 Constitution Hill 01/02/08

13-15 Constitution Hill 19/01/06

13-15 Constitution Hill 16/08/05

13-15 Constitution Hill 25/02/05

13-15 Constitution Hill 02/09/04

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 13-15 Constitution Hill Norwich Norfolk NR3 4HA Lead Inspector Jenny Rose Unannounced Inspection 3rd August 2006 10:50 DS0000027382.V306975.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 DS0000027382.V306975.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. DS0000027382.V306975.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 13-15 Constitution Hill Address Norwich Norfolk NR3 4HA 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) 01603 789450 NO FAX # Mr M Talbot Mrs J Talbot Mr M Talbot Care Home 16 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (12) of places DS0000027382.V306975.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: Constitution Hill is a Care Home that provides services and single room accommodation to 16 residents, 12 falling into the category of Adults with a Mental Disorder and 4 falling into the category of Learning Disability.It is located close to the city centre and its amenities and within easy walking distance there are a number of pubs, shops and takeaways.The home itself is made up of two semi-detached Victorian houses joined together to form one house, resulting in spacious communal accommodation and large gardens. DS0000027382.V306975.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection taking place over 7.5 hours. The Proprietor and Manager were available throughout. There were 14 residents living in the home. Preparation had taken place in the CSCI office and there was a completed Pre-Inspection Questionnaire. Policies and records were examined and a tour of the premises undertaken. The Commission had also sent out survey forms to be distributed by the Home to the residents and their relatives. Completed forms had been received from eight residents and one from a relative and their views have been taken into account in this report. No forms were received from healthcare professionals. A review for one resident took place during the inspection with the social worker and a relative, and a relative with a healthcare professional was looking round the home for initial discussions. Two members of staff were spoken to in private and also one relative. All the residents were seen and spoken to during the inspection; three and four residents were spoken to in different groups and four residents spoken to in private. What the service does well: • This is a family run home and the proprietor/registered manager lives on the premises and is very involved in the day to day running of the home, giving continuity and consistency to the residents. The home has a relaxed, friendly and comfortable atmosphere, providing a homely environment for the residents. There is a multi-agency approach to the care planning for residents and frequent consultation with other professionals. Observation of staff and residents shows that staff understand the needs of individuals and there is good communication. • • • What has improved since the last inspection? • A start has been made on a staff training and development programme and some training is to be provided in translation, as well as English, to meet staff needs. There is still room for improvement in the provision and access to formal training. DS0000027382.V306975.R01.S.doc Version 5.2 Page 6 • • • • Formal supervision and staff appraisal is now taking place and is appropriately recorded. There is a quality assurance system in place and the Commission is now in receipt of a copy of the analysis. There is now a commercial extractor fan in the smoking area to protect non-smoking residents from the effects of passive smoking. The house has been entirely redecorated, inside and out and many carpets renewed. 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. DS0000027382.V306975.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 DS0000027382.V306975.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. People who use this service, and their representatives, have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: There was evidence from two care plans seen that there was a detailed assessment document outlining the needs and abilities of the residents. All aspects of health and social care were covered allowing staff to have plenty of information to assist the residents appropriately. Where a resident had been admitted with the help of Social Services then information was also provided by that agency. On the day of the inspection the relative of a prospective resident was visiting with a healthcare professional to discuss the gradual introduction of the person to the home, taking into account that person’s diverse needs and also the needs of the present resident group. The proprietor also described other planned introductions to the home, which could consist of one or two visits and short stays before decisions for a permanent stay were made. DS0000027382.V306975.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are well set out in an individual care plan and residents are provided with opportunities to maintain or develop their independent living skills within a risk management framework. However, the care plans could be better presented in more securely bound files. EVIDENCE: There is evidence from previous inspections, confirmed on the day, that individual residents’ rehabilitation programmes involve a high level of support of key professionals outside the home. There was a review on the day for one resident, involving a relative and social worker and a meeting with another relative and healthcare professional to discuss the possible admission of a prospective resident. There was evidence in the way of signatures from care plans that individuals were involved in the plans and agreements from care plans case tracked there was good evidence of psychiatric involvement if appropriate. Daily records gave good accounts of how residents were and whether they had had visitors or taken part in activities. DS0000027382.V306975.R01.S.doc Version 5.2 Page 10 Residents spoken to and observed on the day had the freedom to make decisions of their own and were supported to do so. The care plans examined contained contracts and regular reviews with healthcare professionals and social workers. Management of risk takes into account the age, the specialist needs of the residents, balanced with their wish for independence and choice. Where restrictions are in place, the decisions have been made with the resident, for example over such as issues as alcohol. At present care plans are kept in individual folders in a loose-leaf manner. The information contained is recorded well, but warrants being more securely kept in individual bound files, which are also properly indexed for ease of access, especially for reviews with healthcare professionals. This was discussed with the Proprietor who appreciated that a recommendation would be made for this. DS0000027382.V306975.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The home provides opportunities for residents’ personal development and in planning activities for both individuals and the group. Relationships with family and friends, as well as the community, where appropriate, are encouraged and residents have a choice of meals in pleasant surroundings. EVIDENCE: Three residents spoken to described the opportunities they had to pursue their own interests and relationships. One, who was having a review of his supported work possibilities, on the day, described taking part in creating stained glass and he was looking forward to attending family wedding in the near future. He visited his relative regularly and was able to manage his own money and go to the Post Office. He regularly meets a friend, either at his home or in the Home, when he cooks a meal for them both. He cleans his own room and changes the bedlinen. He also enjoys going on holiday abroad. Another said “I am happy here”… “I get out walking”…and…”the food is excellent”. He was also able to visit a relative by train from Norwich and enjoyed reading. Another resident also commented “This place is all right”, he too managed to go shopping and to visit friends and enjoyed sketching and DS0000027382.V306975.R01.S.doc Version 5.2 Page 12 writing, of which there was evidence in his room. Other residents preferred to stay in the home, or to spend time in the garden. There was evidence from the residents’ meetings minutes that residents are able to request activities on an individual and group basis, there are outings to the theatre and to Yarmouth, for example. One relative spoken to on the day expressed satisfaction with the care given in the home and that her relative was happy living there. The manager reported that there was a risk assessment for a new resident on respite care to have a kettle in his room. There is a domestic washing machine for residents to undertake their own washing as part of more independent living, if appropriate. Meals are prepared by support staff, although residents who wish to prepare their own meals, or meals for friends, are supported to do so at appropriate times. The main meal is served in the evening, either in the conservatory or the other communal room and staff were observed asking residents what they would like for their meal and it was from a menu which had been suggested by residents. Residents spoken to said they had enough to eat and all had positive remarks to make about the food. There had been some language difficulties with training in basic food hygiene for some members of staff, but they were seen to be appropriately dressed for working in the kitchen, which was clean and tidy on the day of the inspection. The issue of training is dealt with under standard 32. DS0000027382.V306975.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents receive appropriate personal support provided in a private and dignified way and have access to psychiatric support when necessary. There are arrangements for the safe storage and administration of medicines, which protect residents. EVIDENCE: In terms of personal support, most residents can handle their own personal care, or may just need a prompt from staff. The manager reported that relationships with the local surgery are good and that residents quickly receive attention if it is required. Health and dietary requirements are recorded in each resident’s plan, for example for a resident who is diabetic. On the day, one resident was complaining of toothache for which she received attention in terms of painkillers and an appointment was made at the Dentist. The home’s focus is on rehabilitation and the residents are able to determine their own patterns in respect of daily routines. Where staff feel that a change is required, other professionals such as the Community Psychiatric Nurse or Social Worker are informed so that a muti-agency approach can be taken to support the individuals concerned. The emotional needs of residents are also cared for, as demonstrated following the recent death of a resident in hospital. Those residents wishing to, were enabled to pay their respects at DS0000027382.V306975.R01.S.doc Version 5.2 Page 14 the funeral. As stated elsewhere one resident has a frame following a recent illness and there is a seat in one shower for those residents needing that support. In the care plans examined there were references to regular reviews with the relevant healthcare professionals and easy access to GPs when necessary. The plans also include the support and promotion of self care through observation and prompting and this was also observed on the day. The medication round was observed and arrangements were found to be in order. The Manager explained that the pharmacy has devised a method for residents to be able to take medication out of the home by dispensing it separately, according to the resident’s needs. The records are provided by the local pharmacy and maintained for each individual and noted in the care plans. The Manager also explained that two residents who were self-medicating have risk assessments for this. The Manager, who has 20 years experience, has completed the Boots training, but hopes to complete more advanced training shortly. The medicines are kept in a locked metal cabinet within a locked cupboard and those residents who are able to come to the appropriate member of staff for the medicine to be dispensed. There is a recommendation that photographs be attached to the appropriate medication sheets with the resident’s permission, in order to further protect residents. There is in-house training for other members of staff to dispense medication, which was described by the Proprietor and seen in staff files. DS0000027382.V306975.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Judgement The quality outcome in this area is adequate. This judgement is made using available evidence including a visit to this service. Residents feel safe and listened to. The home has a policy on the protection of vulnerable adults and although members of staff could give a good account of their knowledge, formal training must continue to be pursued to further ensure the protection of residents. EVIDENCE: The home has a complaints policy and procedure and no formal complaints had been made since the last inspection. The Manager records and monitors all comments made and residents are given the opportunity to raise concerns at meetings or through discussion with the Manager and other staff. All the residents spoken to and the comments in residents’ surveys confirmed that residents were well aware to whom they should complain if there were a need. The home also has a policy on the protection of vulnerable adults, including the whistleblowing procedure and this is included in the staff handbook. Staff confirmed they are made aware of adult protection issues during their induction and one could give a good account of what to do in the circumstances of this arising. However, formal training is due to take place within the next few weeks and in view of the necessity for translations of course material for staff whose first language is not English, this issue is dealt with elsewhere in this report. DS0000027382.V306975.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 The quality outcome in this area is good. This judgement has been made using the evidence available including a visit to this service. The residents lived in a safe, homely and clean environment and all areas of the home, inside and outside, are in the process of redecoration and refurbishment. EVIDENCE: During a tour of the premises it was evident that all areas of the home have been redecorated and were in the process of being completed, including the bathrooms mentioned in the last report. There were new carpets in many rooms and the outside had been completely repainted, giving a very bright and welcoming atmosphere to the home. The communal sitting area had been completely refurbished and the conservatory fitted with a commercial extractor fan, as that is the designated smoking area for the home. The doors were also kept closed to protect other areas from passive smoking, which was the subject of concern in the previous inspection. Invitations were accepted to see residents’ rooms, which were seen to be personalised, pleasantly furnished and decorated, or in the process of being redecorated. All areas of the home were seen to be clean and tidy. The support workers duties include cleaning routines and laundry and supporting residents to do DS0000027382.V306975.R01.S.doc Version 5.2 Page 17 this where possible. One resident was pleased to say that he kept his own room clean and changed his bedlinen. DS0000027382.V306975.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 The quality outcome in this area is adequate. This judgement has been made on the evidence available including a visit to the service. The home has worked hard to source training and to give supplementary information to training to members of staff whose first language is not English. Formal staff supervision is now in place, but formal training should continue to be developed in order for staff to support residents even more effectively. EVIDENCE: The staff team in the home work very closely, since the Proprietor lives on the premises and has daily contact with staff and the Manager, with 20 years experience, lives close by and is available on standby when necessary, together with an experienced Deputy. Both the Proprietor and Manager, separately, gave good accounts of the arrangements for standby at the weekends and staffing arrangements for emergencies. Some staff members also share the same accommodation and live close by and as such, the staff have much day-to-day work practice supervision and both members of staff spoken to were able to give a good account of this and recognised the importance of handovers at the end of their shifts and also the importance of completing the Daily Record. There was evidence from the staff files examined of a formal supervision and staff appraisal now in place. From a relative’s survey there was the comment: ”The care provided is of a high quality…the staff are always helpful…take time to discuss problems…” and the residents spoken to and the residents’ surveys confirmed this. From DS0000027382.V306975.R01.S.doc Version 5.2 Page 19 observation on the day, there was very good communication between staff and staff and residents and they were treated with respect and dignity, as well as with good humour. From the staff files it was evident that the necessary checks were in place before staff started work in the home. Both members of staff from overseas had relevant qualifications and experience in their mother country, but had had language difficulties in the examination for Food and Hygiene. The Proprietor reported, and this was confirmed by the staff in question, that this could be and had been rectified by a translation in their mother tongue being available when this examination was resat. The Proprietor reported that the home was a member of a local consortium of residential homes, which is proving to be a useful source of training advice. There is therefore a recommendation that supplementary information in the form of translations is available for all relevant training courses. Also a repeated recommendation that the staff responsible for in house training be provided with training in order to fulfil this role effectively. Also a requirement that staff should continue to be provided with formal training, particularly in the protection of vulnerable adults. The staff spoken to reported that they felt well supported by the management and were enthusiastic about their work in the home, which they enjoyed. One member of staff was anxious to say that the staff from overseas always spoke English in front of the residents and only used their mother tongue in private. Another member of staff said that she found writing much easier than the spoken word, which was helpful in writing records, but she was observed communicating very easily with residents. From the residents’ surveys came the comments: “I have found the staff to be very helpful and caring” and “Yes, they do treat us well…and they do listen to us… and they do act”. These were comments made by residents, who had had no support in completing the surveys. DS0000027382.V306975.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The quality outcome in this area is good. This judgement is made on the evidence available including a visit to this service. The home is well run and there is an open and inclusive management style and a person centred management approach. A capacity to improve exists in the home, as with the development of a formal quality assurance system, and this should result in good outcomes for the people using this service. The home promotes the health, safety and welfare of residents and staff. EVIDENCE: Discussions with Proprietor, Manager, members of staff and residents revealed that residents are consulted on a daily basis about the quality of the service. Observations on the day also show that there is a very open person centred approach to residents. The daily records show the discussions which take place, and any action taken in response to comments made, are recorded. Residents’ meetings are held and provide evidence that residents are informed of events taking place in the home and are able to express their views. DS0000027382.V306975.R01.S.doc Version 5.2 Page 21 The requirement from the previous inspection has been met with an analysis of the July 2006 Quality Assurance Survey received in the office of the Care Commission, from which the home will initiate improvements in the next survey in that surveys for residents will be anonymous, but they were encouraged that most people, other than prospective residents felt there was sufficient information about the home and 100 expressed satisfaction that the residents’ needs were being met. There is evidence from previous inspections that the home has consistently promoted the health, safety and welfare of the residents and that risk assessments on the building and equipment are in place, together with fire safety records and risk assessments, evidence of a Fire Risk Audit dated 31 July 2006 was seen, together with a risk assessment of the pond in the garden containing gold fish, which many of the residents and staff enjoy. The Proprietor gave a good account of the home’s creative approach to alerting residents to the risk of fire, which they practise during fire drills. DS0000027382.V306975.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 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 X X 3 X X 3 x DS0000027382.V306975.R01.S.doc Version 5.2 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 01/09/06 1. YA35 18(1) The registered person must continue with the staff training and development programme. (particularly in the area of the protection of vulnerable adults) 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 YA35 Good Practice Recommendations It is recommended that the member of staff with the responsibility for training be provided with training in order to fulfil this role effectively. This is a repeated recommendation It is recommended that care plans should be more securely kept in individual bound files, rather than looseleaf It is recommended that with the resident’s permission photographs should be attached to the medication sheets DS0000027382.V306975.R01.S.doc Version 5.2 Page 24 2. YA6 3. YA20 4. YA35 to ensure further protection for residents It is recommended that supplementary information in the form of a written translation should be available for training for members of staff whose first language is not English. DS0000027382.V306975.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 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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