Inspection on 28/06/07 for 138 to 138a Mason Way

This inspection was carried out on 28th June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

138 to 138a Mason Way 12/06/06

138 to 138a Mason Way 02/11/05

138 to 138a Mason Way 03/05/05

138 to 138a Mason Way 09/02/05

138 to 138a Mason Way 24/09/04

138 to 138a Mason Way 11/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 138 to 138a Mason Way Waltham Abbey Essex EN9 3EJ Lead Inspector Timothy Thornton-Jones Key Unannounced Inspection 28th June 2007 10:00 138 to 138a Mason Way DS0000017721.V344613.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 138 to 138a Mason Way DS0000017721.V344613.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. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 138 to 138a Mason Way Address Waltham Abbey Essex EN9 3EJ 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) 01992 769113 01992 769113 redhsngltd@aol.com www.rchl.org.uk Redbridge Community Housing Limited [RCHL] Ms Linda Jane Howes Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 8 persons) 28th November 2006 Date of last inspection Brief Description of the Service: 138/138a Mason Way is a residential care home for people with learning disabilities located in a residential area of Waltham Abbey. There are eight people living in this home. The primary aim for this home is to support people to lead as independent a life as possible. The accommodation comprises of two semi-detached houses that provide 4 single bedrooms and communal space in each house. Residents of the houses share a rear garden. There is a local bus service to the nearby town of Waltham Abbey and a parade of neighbourhood shops is available close by. Inspection reports produced by the Commission for Social Care Inspection were kept in the office and were made available to residents and their families/representatives. The service was not able to provide information regarding the range of fees payable. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection site visit took place on 28th June 2007 over 7 hours. The inspection considered a range of records and documents prior to the inspection visit including satisfaction surveys returned from people living at the home and relatives. At the site visit we appreciated the welcome and the assistance received from people resident at the home, the manager and carers. The residents invited the inspector to view all communal areas of the home and individuals were keen to show how comfortable and homely their bedrooms were. Documents were sampled at the time of the inspection and discussions took place with residents, the service manager and carers on duty. Overall the care and support offered to the tenants at Mason Way was good and tenants confirmed they were happy to be living there. What the service does well: What has improved since the last inspection? Some improvements to the environment have been completed since the last key inspection. These include the kitchen areas. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 6 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. 138 to 138a Mason Way DS0000017721.V344613.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 138 to 138a Mason Way DS0000017721.V344613.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): Quality in this outcome area is ‘good’ based upon Standard 2. This judgement has been made using available evidence including a visit to this service. The admission arrangements ensure that people have good information to enable them to make an informed choice about the service. EVIDENCE: No new people have been admitted to the home during the period since the last key inspection. At that time the policies and practice procedures regarding admission remain in place with no revision. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is ‘good’ based upon Standards 6, 7 and 9. This judgement has been made using available evidence including a visit to this service. People can be confident that their assessed and changing needs and personal goals are reflected in individual plans and are reviewed. People are not always assured that they will be consulted about decisions made on their behalf. EVIDENCE: The care management arrangements were sampled as part of case tracking. Two care plans and associated records were sampled and contained a broad range of information addressing the personal, social, emotional and healthcare needs of individuals. The construction of the plan indicated that appropriate decisions, method and reviews were being maintained. The assessment information forms the ‘review sheet’, which on the sample was up to date. The reviews seen at the time of the last key inspection were not signed or dated and did not include evidence of family/representative input or indicate who was present at the review. The sample taken on this occasion indicated 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 10 the same. This could be indicative of people not giving consent to decisions being made that affect their lives. The manager and staff continue to demonstrate a good knowledge of individual’s needs and choices. It is important that the ways of working with people form part of the daily record to ensure that evidence is available to show that methods carers use are linked with the individual plan of care. This was not always evident from the records seen. The service accommodates people who are relatively able to live with minimal supervision and support for the most part and the style of delivery is similar to that of supported living. The daily recording and planning reflects this approach and, for people living at the home, this is positive, since the level and style of support enables people to be as independent as possible. It is noted that the organisation has assessed the needs of one person living at the service whose needs are not being met due to behaviour that challenges. It is understood that an alternative placement is being sought. In terms of the nature of the behaviour, there is some evidence to indicate that recorded incidents may have placed the person or others in the home at some potential risk. The Manager was advised to ensure that service user/staff ratios are reassessed (none evident at the time of inspection) and that deployment to ensure the safety and welfare of all people within the home is maintained. The organisation will need to ensure that people admitted to the home require personal care in accordance with the registration category of the service and whose needs can be met within the Statement of Purpose and the scope and range of carers skills and experience. Assessments for known and planned risks within the care files were appropriate and current. The plans will need to ensure that presenting and immediate risks are fully reflected within plans. See recommendation. Records of tenants meetings with their key workers continue to be maintained and demonstrate that consultation with people take place regularly in a semiformal in addition to informal decisions on a daily basis. In speaking with people living at the home and observation of interaction with carers it was evident that carers support and empower people to make as many decisions as possible for themselves. All people spoken with were confidant and relaxed. Where individual’s rights or choices had been limited through the risk management framework this was appropriately recorded although not all evidenced that people were consulted about the decision making process and were made as part of a risk management strategy. See recommendations. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is ‘good’ based upon Standards 12, 13, 15, 16 and 17. This judgement has been made using available evidence including a visit to this service. People can be confident that they are offered a range of planned activities within the community that allow them to participate in social and occupational opportunities. People living at the home can expect meals and mealtimes to meet with their preferences and lifestyle, although they cannot be assured that the preparation has been competently undertaken. People can expect to be helped to maintain links with friends and family. EVIDENCE: Seven of the 8 tenants accommodated at Mason Way attended further education classes on various subjects, although these are mainly self-help and life skills subjects but also include flower arranging and yoga. Other daily activities include one person who works part time at a pub and charity shop volunteers. One person was in hospital at the time of the inspection visit. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 12 As at previous inspection visits all people living at the home were still actively involved within the local community. Visits to the Cinema and ten-pin bowling are popular. One person regularly attends a local church. People spoken with described the various interests they have during the day and the places they visit, with support. Holidays are enjoyed and the Registered Person (RCHL) contributes toward the cost of holidays, which are arranged by each service user with the help of carers. The relationship between carers and people living at the home was friendly and relaxed. Communication was encouraging and supportive. Upon invitation to view some of the bedrooms in both self-contained dwellings, it was evident that each room was personalised and private to the individual. All have keys to their rooms. The previous inspection reported that people had unrestricted access to the communal areas of the house and the garden. The ethos in the home promoted respect for each other and each other’s space and belongings. This was still evident and actively promoted by carers. Each person has a ‘weekly schedule’ within care planning documentation detailing activities and house tasks etc. The daily records associated with the day-to-day activities were variable in quality. Some were comprehensive, clear and descriptive making clear links with the plan of care. Others were very limited. CSCI sent surveys to relatives as part of the inspection process. Two were returned in time for inclusion within this report. One person was concerned about the home keeping them informed about the progress of their relative who was resident. The other relative also had reservations although said that the home usually kept them informed. The surveys were generally supportive of the service. The kitchens in both houses have been refurbished. A copy of menus was available, which are agreed between the carers and people at the home. The current practice is that each person may select a meal in turn and prepares the meal, with carer support, for the remainder of the occupants. Agreement of the meal to be prepared is sought although an alternative is offered if required. The present catering arrangement may present as a risk since people who are preparing food for others to eat have not received training in food hygiene. It would be reasonable to expect that people who prepare food from raw ingredients have received training or are supervised by a person who has been trained to do so. The home was in possession of ‘Safer food – Better business’ learning pack although this had not been commenced by staff. See recommendations. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is ‘good’ based upon Standards 18, 19 and 20. This judgement has been made using available evidence including a visit to this service. People continue to be supported by the positive ethos of the home and the way in which people are helped to access healthcare professionals. The arrangements for administration of prescribed medicines, however, are not always completed in a way that protects people living at the home. EVIDENCE: Carers were observed throughout the day providing sensitive and flexible support to people with many day-to-day issues. People were communicated with dignity and respect and empowered to have control over their lives as much as possible. People spoken with confirmed they received care and help in the way they preferred and needed. Each had a carer acting as a key worker and as far as practicable were selected by the individual. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 14 The healthcare needs are facilitated as part of the ‘ordinary life’ principles supported by the service. Appointments are made with GP’s and other healthcare professionals as and when required by appointment unless a visit to the home is necessary. All healthcare records were well recorded separately within the care planning arrangements. Each individual’s medication was administered at appropriate intervals at a time to suit the person. Some were supported to administer some or all of their medication themselves by means of a monitored dosage system. Carers make up cassettes of medicines for the week and the record is signed and dated as appropriate. People who are supported this way keep the medicines in a lockable cupboard. Whilst this system does enable people to take more control of the medicines they take, the monitored dosage system is limited in empowering people to eventually take increased control of their medicines. Medication administration records were generally complete although based upon the sample, carers were not always using the system code and the record was unclear as to why medication had been omitted on one record. (See recommendation) Medication storage was appropriate. Competency assessed training in the safer handling and administration of medicines had been provided for all staff within the previous 18 months. Consent regarding the administration of medicines was present on the individual care plans. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is ‘good’ based upon Standards 22 and 23. This judgement has been made using available evidence including a visit to this service. People could be confident their views are listened to and acted upon and assured that the home’s arrangements adequately protect them from abuse and harm. EVIDENCE: The Manager confirmed that no complaints had been received at the home during the period since the previous key inspection. Mason Way operates under the Redbridge Community Housing Limited robust complaints policy and procedure. All policies and procedures received an annual review. People spoken with confirmed they could speak to any member of staff if they had a complaint to make. It is recommended that the complaint and safeguarding policies be produced in improved format easy read option. Training had been undertaken in relation to the staff files sampled. The Manager confirmed that all staff had now received safeguarding training. Discussion with various team members did demonstrate a good awareness of adult protection and staff reported they would be confident to report any suspicion of abuse under the Whistle Blowing policy and procedures. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is ‘good’ based upon Standards 24 and 30. This judgement has been made using available evidence including a visit to this service. Service users benefit from an environment that meets their needs and preferences. EVIDENCE: The accommodation overall was clean, fresh and homely at this visit with well maintained furniture, fixtures and fittings. The location of the home is within an established residential area and offered good access to the local community with a doctor’s surgery and shops close by. The communal lounge areas were comfortable and domestic in atmosphere and homely. People spoken with said they were happy with the décor in their rooms and the communal areas. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 17 A bathroom in one dwelling was noted to have a broken wall light fitting that on closer examination was possible to access live electrical terminals. An immediate requirements notice was placed with the person in charge in respect of this fault. Subsequent to the inspection CSCI was advised by the manager that a temporary repair had been made whilst the fitting is to be replaced and that no danger exists to people at the home. The properties share a garden to the rear. There was a hammock swing and a table and chairs for people to sit at. The manager and staff had sound understanding of health and hygiene matters and infection control. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is ‘adequate’ based upon Standards 32, to 37. This judgement has been made using available evidence including a visit to this service. Whilst the organisation undertakes a robust recruitment practice to safeguard service users, people are not assured that the number of carers in the home meet their assessed needs and cannot be fully confident that all the staff caring for them have been adequately trained. EVIDENCE: Two staff files were sampled in relation to recruitment, supervision, training and development. The recruitment practice meets with regulatory requirements and National Minimum Standards. All required references and checks had been undertaken in the sample seen. Training records were noted at the previous key inspection not to be up to date. The sample on this occasion also indicated a shortfall. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 19 The sample files indicated that a training plan was in existence and that training objectives had been agreed but these had not been met and no follow up or explanation was evident. Based upon an overview of the training requirements identified by carers, some shortfalls were evident. Cares stated that certificates for training courses attended were very slow in reaching the participants. There was no training assessment for the team as a whole available. Less that 50 of carers hold a qualification at NVQ level 2 or equivalent and this does not meet the ration contained within National Minimum Standards. Some carers had attended Learning Disability Award Framework training, which was positive and appropriate. Staff supervision had been undertaken on a regular basis for the sample group although supervision agreements seen had not been signed or dated. The staff deployment method (carer/service user assessment) was unclear and it was not possible to ascertain the adequacy of the number and deployment of carers based upon the needs of people at the home. The Manager stated that the hours are allocated by ‘head office’ and she was unaware of how this was calculated. The inspection was not able to ascertain the suitability of staff deployment since not all service users were at home at the time of inspection, however it was clear that at least one person living at the home, but not present, was challenging in their behaviour to the extent that the person has been assessed as not being suitable to remain at the home. There was no evidence to indicate that staffing levels or ways of working have significantly changed to meet this presenting change in circumstances. This does not meet National Minimum Standards. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is ‘good’ based upon Standards 37, 39 and 42. This judgement has been made using available evidence including a visit to this service. People can be assured that the ethos and management of the home meets with people’s expectation. People using the service cannot be confident that quality assurance and monitoring is sufficiently detailed to evidence quality outcomes are being achieved, however, they benefit from the arrangements for health and safety within the home. EVIDENCE: The Manager is registered with CSCI and is currently undertaking the Registered Managers Award (RMA). The ethos of the service is appropriate and in keeping with the support of people living at the home. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 21 The quality assurance system was viewed although at the time the manager had left the home and it was unclear whether all of the available records were presented. It was noted that at the last key inspection the corporate quality assurance system had been inspected and was found to be in order. On the basis that the information available was limited and the Annual Quality Assurance Assessment (AQAA) data had not been submitted to CSCI there was insufficient information made available to determine the adequacy of the system. CSCI surveys sent to the home prior to this inspection. Four service user and two surveys from relatives had been returned. Overall the surveys were positive. The most recent report of a visit by the person in control was dated 19.06.07 and records indicate that visits are in accordance with requirements. Redbridge Community Housing Limited had robust policies and procedures relating to Health and safety of the people living in the home, the staff and the buildings. The home has a number of safety monitoring and detection systems for example, fire detection, fire equipment, emergency lighting, portable appliance testing and Substances Hazardous to Health (COSHH). These were checked at random and found to be well maintained. 138 to 138a Mason Way DS0000017721.V344613.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 3 2 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 3 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 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 YA33 Regulation 12(1)(b) 12(3) 14(2)(a) 18(1)(a) 24(1)(2) Timescale for action The number of carers to provide 31/08/07 personal care must be suitable for the numbers and needs of persons resident. The quality assurance and 31/08/07 monitoring system used at the home must be available for inspection. Requirement 2. YA39 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 It is a recommendation of good practice that the registered manager develops a system that shows when decisions are made on behalf of people without their consent and the reasons for this, linked to risk assessment. It is recommended that the care planning arrangements be developed to reflect a person centred and fully consultative style. It is recommended that all people who prepare food for others are trained to Foundation level Food Hygiene Award, or equivalent, or the person supervising has attained the Intermediate Food Hygiene Award, or DS0000017721.V344613.R01.S.doc Version 5.2 Page 24 2. YA17 138 to 138a Mason Way 3. YA20 4. 5. 6. YA23 YA36 YA32 YA35 equivalent to ensure that food hygiene standards are observed. It is a recommendation that the system code on the medicine administration system be used rather than nonsystem codes to ensure that a suitable audit can be undertaken. It is a recommendation that the service complaint and safeguarding policy be produced in an easy read format for easier access to people living at the home. It is a recommendation that the supervisory contracts in place should be signed and dated by each party to signify the role and relationship within the supervisory process. It is recommended to further develop the staff training and development system to identify carer training and development needs and to increase the number of carers qualified to NVQ level2 in care practice or equivalent. 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 138 to 138a Mason Way DS0000017721.V344613.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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