Inspection on 29/06/06 for 16 Mansfield Road

This inspection was carried out on 29th June 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

16 Mansfield Road 09/07/07

16 Mansfield Road 01/11/05

16 Mansfield Road 03/06/05

16 Mansfield Road 27/05/04

16 Mansfield Road 13/05/03

Similar services:

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

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

CARE HOME ADULTS 18-65 Mansfield Road (16) Heanor Derby Derbyshire DE75 7AJ Lead Inspector Anthony Barker Key Announced Inspection 29th June 2006 09:15 DS0000020050.V301827.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 DS0000020050.V301827.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. DS0000020050.V301827.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mansfield Road (16) Address Heanor Derby Derbyshire DE75 7AJ (01773) 711270 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) None United Response Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000020050.V301827.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2005 Brief Description of the Service: This service provides accommodation for four younger adults with severe learning disabilities and associated conditions including autism, sensory disability and challenging behaviour. Four single bedrooms are provided in a detached house situated on a bus route near to the town centre of Heanor. DS0000020050.V301827.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 8.5 hours and was a key unannounced inspection. The last inspection took place in November 2005 and was unannounced. The Acting Manager and two other staff members were spoken to, records were inspected and there was a tour of the premises. Two service users were ‘case tracked’ so as to determine the quality of service from their perspective. The service users had high levels of dependency and were able to make only limited contributions directly to the inspection process. However, observations were made of their behaviour and their interaction with staff. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. What the service does well: What has improved since the last inspection? The statement of purpose had improved and individual plans of care had been introduced. The latter were holistic in nature and being reviewed regularly. Additional information had been incorporated into individual care records. The safety of service users in the bathroom had been fully addressed. Good practice was being followed regarding the recruitment of staff and mandatory training sessions were being provided. An annual plan had been developed and the Environmental Health Officer’s recommendations had been met. Twelve of the twenty-one requirements, and six of the seven recommendations, made at the last inspection had been met. DS0000020050.V301827.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. DS0000020050.V301827.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 DS0000020050.V301827.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): 1&2 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Prospective service users had the information they would need to make an informed choice about where to live. Existing service users’ needs had been assessed before admission to the Home. EVIDENCE: The Home’s Statement of Purpose had still not been personalised to the Home in a number of places – making it look like a draft copy – though other improvements had been made since the last inspection. All four service users were admitted from Morley Manor nine years ago when that establishment closed. Previous inspections had identified good quality documentation of the pre-admission process. DS0000020050.V301827.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 Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service. Not all service users’ needs, and risks to which they were exposed, were reflected in their individual plans of care. They were being supported to make decisions about their lives. EVIDENCE: As at the last inspection one of the four service users’ care plans was not in the Home. However, there were improvements noted: • each service user now had an holistic care plan developed within the Home, • care plans were being reviewed regularly (except for Behaviour Management Plans – see standard 9 later), • the service users’ date of admission and a recent photograph were present on the files examined, • the front information sheet, on each file, had been redeveloped, • the key worker’s name had been recorded. Newly devised care plans had been completed satisfactorily but, overall, files had not been consistently kept and there was a need to raise recording standards. Not all records were dated, including care plan reviews. The Acting Manager spoke of plans to review care plans every six months. He also said the language and format of care plans was being considered in the context of DS0000020050.V301827.R01.S.doc Version 5.2 Page 10 service users’ understanding. For instance, the use of icons would help some service users but not others. There was no recorded evidence on files of service users’ representatives being involved in the care planning process. On the wall of the staff sleep-in room there were ‘Important to/Important for’ charts for service users – a new part of the Home’s person centred approach, the Acting Manager explained. Whilst all of the service users had difficulty with ordinary communication, staff had developed techniques to enable them to understand the expression of preferences and choices in very individual ways, some following years of acquaintance with the service users. There was a range of capabilities within the service user group and two service users were able to express more complex choices than the others. Service users had chosen holidays through staff showing them photographs, magazines and maps. Staff had provided multiple choices, which was more appropriate to their level of decision-making skills than asking open-ended questions. The service users had little understanding of money and did not manage their finances. However, three service users had been assisted to open individual bank accounts. Consideration was still being made to introduce advocates to the service users, the Acting Manager said. The encouragement of independence was a key part of the Home’s philosophy. Written Behaviour Management Plans did much to guide and support staff in appropriate behaviour management programmes regarding two service users. These were comprehensive and acted as recorded risk assessments. One of these Plans had not been regularly reviewed. The behaviour of the other two residents was not a management issue, the Acting Manager said. Some recorded risk assessments were being reviewed but others were considerably out of date. One service user’s set of risk assessments comprehensively addressed risks in the community and showed evidence of increasing his independence and developing his skills. However, some potential risks to service users had not been subject to an assessment. DS0000020050.V301827.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 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Service users were able to take part in valued activities and their rights and responsibilities were recognised. They were part of the local community and generally maintained family links and friendships. They enjoyed their meals. EVIDENCE: Each service user attended a day services provision four days each week, offering them opportunities to take part in valued activities. They had a ‘personal day’ at the Home each week. At the time of this inspection they were not receiving any educational activities although they had in the past. The Acting Manager gave examples of how service users show they value undertaking domestic activities within, and outside, the Home and on holiday. The ‘Important to/Important for’ exercise will address personal fulfilment, the Acting Manager explained. Evidence was seen in care records of a broad and varied range of opportunities being made available to service users. Daily trips and local walks showed that service users were encouraged to be part of the community. Community DS0000020050.V301827.R01.S.doc Version 5.2 Page 12 facilities used included local shops, pubs, restaurants and the local leisure centre. Activities for the service users at the latter included swimming, bowling and badminton. The Acting Manager spoke of plans to increase staffing levels on most evenings in order to further match services to individuals’ needs. He said this could give rise to further community involvement for service users. Three of the service users had continued to maintain links with their families – one on a very regular basis involving overnight visits to the family home. Another had no links with any family but as he is the most able he seemed to enjoy a more varied range of social activities and one to one staff supports and had been able to visit Jamaica. He had also been supported to visit various Afro-Caribbean social facilities in Derby and Nottingham, where he had been exposed to cultural influences not available in the Heanor locality. The majority of social contacts for service users had been with their family members or with staff. However, social evenings were held periodically at United Response Day Services to enable service users to meet up with others from other United Response homes in order to maintain relationships and develop new friendships. Routines in the Home were structured to reflect the needs of the service users who had varying degrees of autism. All service users were involved in household shopping in local stores on their ‘personal days’ and to varying extents in food preparation - according to their ability. Each of them cleared up after their meal. Service users were encouraged to wear dressing gowns when going for a shower, thus addressing their dignity needs. They were able to lock the bathroom door, for privacy, although only one service user actually did this. The Acting Manager said that consideration was being given to changing the use of a small ground floor office to an en-suite shower room for one resident in order to provide him with increased privacy. The kitchen contained good levels of foodstocks including fresh fruit and vegetables. The Home provided a nutritious and varied menu to service users. The meal, on the evening of this inspection, was seen to be a relaxed occasion with a tasty-looking meal. This was clearly being enjoyed by the service users. Two staff were sitting with the service users. Two service users had helped prepare the vegetables. Files contained no ‘Likes/Dislikes’ lists – for food or otherwise. DS0000020050.V301827.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 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Service users were being supported in the way they preferred and their physical and emotional health needs were met. They were protected by the Home’s procedures for dealing with medicines. EVIDENCE: The timing of the day’s activities such as going to bed was flexible and decided individually by service users. One member of staff described daily activities that supported the general impression that arrangements within the Home were relaxed. Getting up in the morning was a more structured arrangement due to the need for rituals and patterns dictated by the service users’ autism. A keyworker system was in place. Staff said that two service users had higher personal care needs than the others and all needed some prompting by staff. Staff were able to describe service users’ involvement in domestic activities, and on trips to local shops, that confirmed the promotion of their independence. Also, examples were discussed from which it was clear that service users’ dignity was maximised. All service users were registered with the same GP practice and staff reported no difficulties in arranging support. There was good support from specialist health professionals, such as psychologist, audiologist and diabetic clinic, as DS0000020050.V301827.R01.S.doc Version 5.2 Page 14 well as general health professionals such as a chiropodist and dentist. Evidence of this was seen on files. Support from the district nurse, and continence advisor, had been used in the past in relation to continence management problems experienced by two service users. Floor covering in a good quality, and visually pleasing vinyl, was in use in their bedrooms. All service users attended clinics or outpatient services with staff support. The ‘well man’ clinic was a facility being used by all four service users every six months. There was evidence of very regular health checks being carried out, such as dental and optical, as well as regular weight recording. Service users were all described as being generally in good health although one had developed diabetes. Medication was being prescribed to all the service users – none managed their own medication. The storage, administration and recording system was satisfactory. One member of care staff said that ‘prn’ (as and when required) medication was just occasionally used by two residents and described good practice in its recording. A good written policy on the use of ‘prn’ medication had been seen at a previous inspection. Individual protocols regarding the circumstances for administrating ‘prn’ medication to a service user was recorded on individual files. Staff stated that all staff had received medicine training from the Home’s pharmacist and several certificates were seen that supported this. DS0000020050.V301827.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 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from the Home’s complaints procedure and were being protected from abuse. EVIDENCE: The Home’s complaints procedure was displayed and was well worded, with the use of suitable symbols. One staff member described a complaint from a member of the public, received around Christmas 2004, that was found to be unsubstantiated. This was dealt with by headquarters staff but no documentation was in the Home. The staff member went on to describe how individualised communication systems were used to ensure staff knew whether service users were unhappy about something. Appropriate written policies and procedures, relating to the protection of service users from harm, were seen and provided staff with a good level of understanding. One staff member said that staff were regularly reminded of the Home’s Whistle Blowing policy. All staff had attended Adult Protection training and were attending SCIP training bi-annually: this provided staff with skills to appropriately manage aggressive behaviour in adults with learning disability. Staff were observed to be interacting with service users in a caring and respectful way. DS0000020050.V301827.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): 24,26 & 30 Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service. Service users were living in a homely, clean and comfortable environment. Their bedrooms promoted their independence. Service users could be considered at some risk from poor hygiene practices. EVIDENCE: The Home had generally high material standards: it was attractively decorated and furnished and was homely. However, the paintwork on interior wooden window frames was still in a poor state. Staff said that replacement windows had been agreed by the landlord and were still due to be fitted. An additional set of handrails had been fitted beside the stairs and new carpets had been fitted in the hall, stairs and landing. The garden was being kept tidy by a firm of gardeners and service users were also involved in maintaining the garden. Bedrooms were all nicely personalised and well furnished and each had every facility available for service users. Two bedrooms had new items of furniture. The décor in one bedroom was culturally appropriate for the service user. Bedroom doors had locks and staff could access these rooms, in an emergency, by means of a ‘master key’. However, there was still only one key available to staff. Although no resident was known to have locked their door DS0000020050.V301827.R01.S.doc Version 5.2 Page 17 from the inside there was still a risk of this happening. In these circumstances, should a fire develop, staff may not be able to act as quickly as necessary. The Home was clean and the washing machine had a sluicing facility. Staff confirmed that the practice of placing one service user’s used continence materials in standard bin bags continues. There was correspondence in the Home from the Department for Environment, dated 4 April 2006, setting out the need for a health professional to make a risk assessment regarding “wastes from human hygiene”. It was still unclear whether the Home was complying with the Water Supply (Water Fittings) Regulations, 1999. DS0000020050.V301827.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): 32,33,34,35 & 36 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Service users were supported by a well-trained staff team though levels of appropriate qualifications were low. They were being protected by the Home’s recruitment procedures. Service users were not benefiting from well-supervised staff. EVIDENCE: As at the last inspection, just one member of staff - 14 of the staff group had achieved a National Vocational Qualification (NVQ) in Care at level 2. Three further staff were undertaking this qualification. The Acting Manager confirmed there were no staff vacancies and no agency staff had been employed since the last inspection. At the start of this inspection staff were not aware of the Acting Manager’s whereabouts and it was noted from the staffing rota that the Acting Manager’s name was missing. Also, staff were only identified by their initials on the rota, which could potentially make it difficult to positively identify staff. The staffing rota was not examined in detail and an assessment of the adequacy of staffing levels was not made. The Acting Manager had previously contacted the Commission to speak of his plans to reduce staff on the morning shift from two to one and had been advised to produce risk assessments for each service user, as well as an overall risk assessment, before progressing. Staff shared concerns, at this inspection, about these plans – citing the range of service users’ needs and the DS0000020050.V301827.R01.S.doc Version 5.2 Page 19 task of preparing breakfast. The Acting Manager agreed to address these concerns through the planned risk assessments. The file of a staff member appointed in October 2005 was examined and all pre-employment information and documents required by Regulations were found to be in place. The Acting Manager explained that all new staff started Learning Disability Award Framework (LDAF) accredited training on appointment, starting with induction training. The ‘signed-off’ LDAF Induction Task Book for the staff member appointed in October 2005 was seen. Staff training documents were examined and these showed that staff were being provided with mandatory training at appropriate intervals. Additionally, all but one staff had attended training in Makaton sign language and annual refresher training in SCIP (see Standard 23 earlier in this report) was planned, the Acting Manager reported. Not all staff were being provided with formal supervision at two monthly intervals. DS0000020050.V301827.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 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from a well run Home with good quality assurance systems. Their health and safety was being protected except for the insecure storage of cleaning materials. EVIDENCE: The Acting Manager had worked with adults with learning disabilities for 15 years and had managed services for this group of people for ten years. He was suitably qualified to NVQ level 4 and was a SCIP trainer. He said he was currently completing an application to be registered manager of the Home. The Acting Manager stated that he had undertaken quality assurance visits to the Home during May and June 2006 but records of these visits could not be found in the Home. A comprehensive Annual Service Plan for 2005/6, including target dates, was examined. The United Response Active Support Co-ordinator was undertaking periodic ‘practice monitoring’ visits to the Home DS0000020050.V301827.R01.S.doc Version 5.2 Page 21 and was sending biannual questionnaires to staff and relatives as part of the Company’s quality assurance programme. Good food hygiene practices were being followed, including storage and recording of food temperatures. The lockable under-sink cupboard contained cleaning materials but was unlocked. There were no Product Information Sheets available, as required by the Control Of Substances Hazardous to Health (COSHH) Regulations. The larder cupboard flooring had been replaced since the last inspection. Accident/Incident Records were examined – good recording practices were being followed. DS0000020050.V301827.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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 X 2 X DS0000020050.V301827.R01.S.doc Version 5.2 Page 23 Yes 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 YA6 Regulation 17(2) & (3)(b) Sch 4 Requirement All records required to be kept in the Home must be available for inspection at all times. (Previous timescale was 01/12/05) All potential risks to service users must be subject to a written risk assessment. Risk assessments, including Behaviour Management Plans, must be reviewed regularly. The Home must arrange for a health professional to make a risk assessment regarding the disposal of continence materials. If there is a risk of infection then the wastes may be hazardous and will need to be consigned as hazardous waste. (Previous timescale was 01/12/05) All staff must be appropriately supervised at appropriate intervals. (Previous timescale was 01/09/05) Timescale for action 01/08/06 2. YA9 13(4)(c) 01/09/06 3. YA9 15(2)(b) 01/09/06 4. YA30 13(3) 01/09/06 5. YA36 18(2) 01/09/06 DS0000020050.V301827.R01.S.doc Version 5.2 Page 24 6. YA42 13(4)(a)(c) The door to the cleaning materials cupboard must be kept locked at all times. (Previous timescale was 01/12/05) 01/08/06 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. Refer to Standard YA1 YA6 YA6 Good Practice Recommendations The Statement of Purpose should reflect the actual services of this Home. (This was a previous requirement) Recording standards on service users’ files should be improved. Care plans should be reviewed with the involvement of service users together with relatives, advocates or other representatives. Evidence of this involvement should be in the form of a signature. Each service user’s plan of care should be recorded in a language and format suitable to each individual and the relevant service user should hold a copy. However, if this is inappropriate a copy should be given to the family/professional representative to sign. The Manager should record the reason for this within the care plan. (This was a previous requirement) Service users’ ‘likes & dislikes’, including food, should be identified and recorded on files. The individual record of protocols regarding the circumstances for administrating ‘prn’ medication to a service user should be kept on the door of the medication cabinet as well as on service users’ files. A copy of all complaints documentation should be kept in the Home. Internal paintwork on bedroom windows should be repaired. (This was a previous requirement) Staff should, at all times, be able to quickly access locked bedrooms, should an emergency arise. (This was a previous requirement) The Home should comply with the Water Supply (Water Fittings) Regulations of 1999. (This was a previous requirement) 50 of the care staff should achieve an NVQ in Care at DS0000020050.V301827.R01.S.doc Version 5.2 Page 25 4. YA6 5. 6. YA17 YA20 7. 8. 9. 10. 11. YA22 YA24 YA24 YA30 YA32 12. 13. 14. 15. YA33 YA33 YA36 YA39 level 2, at least. (This was a previous recommendation) The staffing rota should include the Acting Manager and should include full staff names. Risk assessments, relating to staffing levels on the morning shift, should be developed, as planned. The registered person should ensure that all staff are appropriately supervised at least six times a year. Monthly visits to the Home under Regulation 26 should be available, in the Home, at all times. (This was a previous requirement) DS0000020050.V301827.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000020050.V301827.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!