Inspection on 02/07/07 for 17 Ella Bank Road

This inspection was carried out on 2nd July 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

17 Ella Bank Road 08/05/08

17 Ella Bank Road 17/08/06

17 Ella Bank Road 25/10/05

17 Ella Bank Road 11/03/05

17 Ella Bank Road 14/07/04

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

CARE HOME ADULTS 18-65 Ella Bank Road (17) Heanor Derbyshire DE75 8PA Lead Inspector Tony Barker Key Unannounced Inspection 2nd July 2007 09:15 Ella Bank Road (17) DS0000019979.V340175.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 Ella Bank Road (17) DS0000019979.V340175.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. Ella Bank Road (17) DS0000019979.V340175.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ella Bank Road (17) Address Heanor Derbyshire DE75 8PA 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) (01773) 760806 None United Response Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Ella Bank Road (17) DS0000019979.V340175.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2006 Brief Description of the Service: 17 Ella Bank Road is a detached house situated on a residential road on the outskirts of Heanor. Service users are provided with adequate accommodation and single rooms. There is a rear garden. Ella Bank Road offers personal and social care to people with a severe learning disability with associated conditions that may include autism, sensory disability or challenging behaviour. Activities are planned to meet individual needs. The fees for the Home are from £1149 to £1513 per week. A copy of the last inspection report from the Commission for Social Care Inspection (CSCI) is available, to service users and visitors, in the office. Ella Bank Road (17) DS0000019979.V340175.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 8.25 hours and was a key unannounced inspection. The service users all had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed working with and being cared for by staff. The Acting Manager, Senior Support Worker with Additional Responsibilities (SSWAR) and one senior support worker were spoken to and records were inspected. There was also a tour of the premises. One service user was case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The preinspection, Annual Quality Assurance Assessment, questionnaire had not been returned at the time of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Service users’ care plans must be kept under review and the Home’s care planning and recording system should be improved. When ‘as and when required’ medication is administered to service users it must be clearly recorded and written procedures, and individual written protocols, should be available in relation to such medication. There must be a date of opening on all medication with a reduced expiry once opened. The Acting Manager must make application to become the Home’s Registered Manager. Improvements should be made to a number of the Home’s records, quality assurance systems and staff training. Ella Bank Road (17) DS0000019979.V340175.R01.S.doc Version 5.2 Page 6 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. Ella Bank Road (17) DS0000019979.V340175.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 Ella Bank Road (17) DS0000019979.V340175.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): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the Home was available to prospective service users, and people placing them, in order to make an informed decision about whether the service is right for them. EVIDENCE: The Acting Manager produced copies of the Home’s Statement of Purpose and Service Users’ Guide but these were not current, he said. These 2005 versions had been reviewed in October 2006 but he could not find the latter. A copy of the previous inspection report from the Commission for Social Care Inspection (CSCI) was available, to service users and visitors, in the office. There had been no service users admitted since the previous inspection. The Acting Manager confirmed he was aware of the need to ensure that a full assessment of need is provided before admission, in order to guide staff in meeting the person’s needs. Ella Bank Road (17) DS0000019979.V340175.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): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ individual plans of care were not person centred, or being reviewed regularly, so they could not be sure that their personal care needs would be fully met. EVIDENCE: The care planning documents for the case tracked service user were examined. The last formal care plan review meeting, initiated by the person’s care manager, had been recently held and there was a comprehensive set of minutes. The service user and external supporters had been present. The Home’s own care planning documentation was found to be a fragmented and rather inaccessible system, within a broken ring binder. ‘Personal Support Plans’ were in place covering a number of issues although not fully holistic and not ‘person centred’. Many of these documents had not been reviewed for over a year and contained comments that were no longer relevant to the service user. The Acting Manager said he planned to review care plans each six months in future. He produced a ‘mock’, person centred review report, regarding another service user, completed two weeks earlier. He stated that Ella Bank Road (17) DS0000019979.V340175.R01.S.doc Version 5.2 Page 10 this was the model of future care planning documentation for all service users and the Inspector accepted it was a considerable improvement on the current system. The Senior Support Worker who was spoken to said she, and all her colleagues, had received training in Person Centred Planning in May 2007. The senior support worker spoken to gave examples of service users making their own decisions and choices, with staff assistance. These included showing the case tracked service user pictures of destinations while planning a holiday. The Inspector observed choices of drink being offered to this service user on the morning of this inspection. One generic risk assessment was on the case tracked service user’s file. This made some limited reference to the benefits from taking risks but these were not recorded in the relevant section of the form. Another service user’s ‘benefits from taking the risk’ had been recorded but they were not fully personalised to the service user. The senior support worker confirmed that service users benefit from taking risks when, for instance, they cross the road or undertake activities such as roller-blading, horse riding, disco dancing and going on holiday. Ella Bank Road (17) DS0000019979.V340175.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): 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. The Home provided activities and services that were age-appropriate and valued by service users and promoted their independence. EVIDENCE: Two of the service users were being provided with four days a week day service at a Derbyshire County Council establishment and the third was receiving a similar day service two days a week. On other week-days, service users were being supported by care workers from the Home, with a view to increasing involvement in the local community. The Acting Manager stated that closure of a United Response day service resource would release funds to provide support to service users in voluntary or paid work. Voluntary work opportunities for the case tracked service user were being sought, the Acting Manager explained. There had been two trials of the service user taking a local dog for a walk, assisted by a member of staff. The senior support worker spoken to gave examples of service users taking part in activities that were valued by them and fulfilling. The case tracked service user was described as Ella Bank Road (17) DS0000019979.V340175.R01.S.doc Version 5.2 Page 12 showing great pleasure in walking and this was in evidence on the day of the inspection. There was evidence of increased service user involvement in the local community. For example, before January 2007, a member of care staff – a qualified hairdresser - used to cut service users’ hair. Now they go to a local hairdresser, the Acting Manager said. The senior support worker described how service users go to local shops, hairdressers, swimming pool and bowling alley. She said that two service users had become quite well known in local shops and one in local cafés. She stated that she found the increasing contact that service users were having with the community to be personally rewarding for her, adding that more of this would improve public attitudes to people with learning disabilities. There was generally good contact between service users and their relatives. The case tracked service user has a befriender too who had been a staff member at a previous care home and takes the service user out for meals as well as attending care plan review meetings as an advocate. The same service user is friendly with another service user from a nearby care home and they meet each week at a disco. The senior support worker provided evidence of daily routines being flexible and promoting service users’ independence. These included bathing routines and food preparation. She explained that service users appreciate routines but these are flexible to reflect their personal preferences. The case tracked service user was observed being encouraged by staff to choose and prepare lunch on the day of this inspection. The SSWAR said the service user had gone to the kitchen cupboard to choose the items although it had taken some time before staff could be sure exactly what the person was wanting to eat. Food stocks were examined and found to be adequate. These included fresh fruit and vegetables. The Home’s menus indicated that meals were balanced and nutritious. The food preferences of service users were on file. The senior support worker said that all service users were involved in food shopping, preparation and clearing up after meals. Ella Bank Road (17) DS0000019979.V340175.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): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inadequate medication records and procedures mean that service users may not receive medication appropriate to their needs at the time they need it, thereby putting them at risk of harm. EVIDENCE: The senior support worker spoken to confirmed that service users’ privacy needs were met by, for example, ensuring that bedroom and bathroom doors were closed when service users are changing or bathing. Handrails were in place to maximise service users’ independence in front of the premises although these did look somewhat institutional. The Acting Manager said there were plans to address this matter. Service users’ likes and dislikes were recorded on file. The Acting Manager and staff on duty were observed treating the case tracked service user with sensitivity and patience throughout the day of the inspection – the other two service users were out at day services. There were positive interactions later in the afternoon between staff and all service users with an appropriate element of fun in these relationships. There was evidence on file of a good range, and appropriate frequency, of health checks on service users. Health appointments were being recorded in Ella Bank Road (17) DS0000019979.V340175.R01.S.doc Version 5.2 Page 14 ‘My Health File’. This was a small, compact and well-designed file, in place since early 2007, that was appropriately person centred. Many parts of these files had still to be completed. Further details arising from health appointments were being recorded on ‘Report/Feedback’ sheets. The Home’s medication recording system was examined and the system of recording ‘prn’ (as and when required) medicines was found to be unsafe. Regarding three separate doses of Lorazepam ‘prn’, administered to the case tracked service user the previous week, there was no note of the time administered or explicit reasons recorded. Neither was there an individual written protocol on file for the administration of Lorazepam ‘prn’ to this service user although there was one in place for paracetamol ‘prn’ for the person and a protocol for Diazepam ‘prn’ for another service user. However, this latter protocol did not make reference to the maximum dose to be administered over a 24-hour period. The Acting manager could find no United Response written procedures covering the use of ‘prn’ medicines. A tub of Sudocrem had not been dated when opened. Sample staff signatures were recorded. Medication was being securely stored. The senior support worker spoken to said she had received training in the safe use of medicines within the past 12 months. Ella Bank Road (17) DS0000019979.V340175.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): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good procedures for handling complaints and abuse were in place ensuring service users were fully protected. EVIDENCE: The Home’s complaints procedure was displayed in the entrance hall. It was satisfactory and included some symbols to help with service users’ understanding. Some elements of it needed updating. The Acting Manager stated that there had been no complaints received by the Home. An appropriate complaints record form was available for such use. The Acting Manager stated that all care staff had been provided with training on keeping adults safe from abuse. The senior support worker spoken to confirmed she had received this training and showed some awareness of the Home’s ‘Whistle Blowing’ policy. She thought United Response would be supportive following whistle blowing but said she had not read the policy for a while. The Home had a satisfactory written policy on responding to incidents of abuse and Derbyshire Reporting Sheets were in place. A record of the physical restraint used on the case tracked service user was examined. The Manager explained that all incidents, of staff physically restraining service users, were recorded on an Incident Form. The record examined contained inadequate details concerning the location of the restraint, the duration of the actual restraint, the part of the body held and the name of the staff member restraining. Records of the case tracked service user’s monies were checked and it was noted that good recording and monitoring practices were being followed. Ella Bank Road (17) DS0000019979.V340175.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): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were living in a safe, hygienic and well-maintained environment, which was furnished to a good standard. EVIDENCE: The Home was attractively furnished and had a homely feel to it. The Acting Manager stated that a full redecoration of the Home was imminently due as well as replacement floor coverings in most ground floor rooms. Carpets in two service users’ bedrooms were rucked and stained. The Acting Manager said there were plans to replace these. All bedrooms were attractive and personalised. In one bedroom the radiator top cover was missing and this matter was also being addressed. The rear garden was tidy and had a double swing and trampoline that service users found stimulating, staff said. The laundry room contained a washing machine and dryer. Staff assured the Inspector that the washing machine’s 95-degree programme, with pre-wash, would be used with any soiled laundry. There were no unpleasant odours in the Home at the time of this inspection. The Home was clean and hygienic. Ella Bank Road (17) DS0000019979.V340175.R01.S.doc Version 5.2 Page 17 The Inspector accepted that the behavioural problems exhibited by one service user necessitated lack of towels and toilet tissue in the communal toilet, and that hygienic alternatives were in place. Ella Bank Road (17) DS0000019979.V340175.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): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home had a stable group of well-recruited and qualified staff to ensure that service users were safe and their needs were met. EVIDENCE: All of the nine permanent and two relief care staff had achieved a National Vocational Qualification (NVQ) to level 2 or above. Three had a NVQ at level 3 and one at level 4. This more than fully met the National Minimum Standard to maintain a staff group with at least 50 qualified staff, and is commendable. No staff had been appointed since the last inspection. However, the file of a support worker appointed in October 2005 was examined. All matters relating to her recruitment were satisfactory and as required by Schedule 2 of the Regulations. The degree to which this standard was met is commendable. The Acting Manager stated that all staff had been provided with mandatory training except that... Ella Bank Road (17) DS0000019979.V340175.R01.S.doc Version 5.2 Page 19 • three night staff had not had the necessary six-monthly Fire Safety training. The Acting Manager said that a training video was available at Headquarters, • four staff were due to be provided with Basic Food Hygiene refresher training in December 2007. There was no ’at a glance’ training matrix available to confirm this. The senior support worker who was spoken to said she had attended a range of mandatory training courses over the past 12 months. The file of the support worker, appointed in October 2005, indicated that she had followed induction and foundation training that meets the specifications laid down by ‘Skills for Care’. Ella Bank Road (17) DS0000019979.V340175.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): 37,39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home’s Acting Manager was not registered with the CSCI and had therefore not proved himself fit to manage the Home and hence ensure the health, safety and welfare of the service users. EVIDENCE: The Acting Manager had 16 years experience of working with people with learning disabilities and had an NVQ in Care and Management at level 4. However, he was not registered. He stated that he had made application in early 2007 to the CSCI, to become the Registered Manager, but this application had not been received. Records of the monthly, unannounced audit visits to the Home, undertaken on behalf of the Registered Provider, were examined. These were satisfactory apart from the absence of any record of interviews with staff. An additional Ella Bank Road (17) DS0000019979.V340175.R01.S.doc Version 5.2 Page 21 quarterly management audit was also being undertaken. The Acting Manager stated that the current Service Plan was being revised to provide a set of objectives for 2007/08. He said that one of the new objectives would be to review alternatives to the current day services provided. The Acting Manager said that all United Response staff had completed satisfaction questionnaires recently – the outcome not yet being available. He said that questionnaires were also due to be sent to the three service users’ relatives, and care managers, soon. Cleaning materials were being safely stored in locked cupboards under the laundry room sink and Product Information Sheets were kept in the office near by. A sheet of first aid measures to be taken in the event of an accident with cleaning materials was kept on the laundry room notice board. Good food hygiene practices were being followed. Accident records were being appropriately maintained and environmental risk assessments were in place. Records of monthly fire drills and weekly fire alarm tests were also in place. Ella Bank Road (17) DS0000019979.V340175.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 2 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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Ella Bank Road (17) DS0000019979.V340175.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. 1. Standard YA6 Regulation 15(2)(b) Requirement Timescale for action 01/08/07 2. YA20 3. YA20 4. YA37 Service users’ care plans must be kept under review so that they continue to reflect current personal needs. 13(2) When ‘as and when required’ medication is administered to service users it must be clearly recorded, to ensure that people receive medication appropriate to their needs at the time they need it. 13(2) There must be a date of opening on all medication with a reduced expiry once opened to ensure the safety of service users. CSA 11(1) The Acting Manager must make application to become the Home’s Registered Manager. This is in order to provide the CSCI with evidence that he is fit to manage the Home and ensure the health, safety and welfare of its service users. 01/08/07 01/08/07 01/08/07 Ella Bank Road (17) DS0000019979.V340175.R01.S.doc Version 5.2 Page 24 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 YA1 Good Practice Recommendations Copies of the Home’s Statement of Purpose and Service Users’ Guide, reviewed in October 2006, should be maintained in the Home and available to service users and visitors. The Home’s care planning system should be holistic, easily accessible and take a ‘person centred approach’. Records should clearly indicate how service users are supported to take risks as part of an increasingly independent lifestyle. Handrails in front of the premises should be less institutional in appearance. Individual written protocols should be in place regarding the administration of all ‘as and when required’ medication. Protocols should make reference to the circumstances when the medication should be administered, the dose to be administered and the maximum dose in any 24 hour period. There should be a written procedure covering the safe use of ‘as and when required’ medicines. The Home’s complaints procedure should be updated. Staff should be reminded of the Home’s ‘Whistle Blowing’ policy and receive their own copy of this. Records, of staff physically restraining service users, should contain more explicit details concerning the location of the restraint, the duration of the actual restraint, the part of the body held and the name of the staff member restraining. Plans to replace the rucked and stained carpets in two service users’ bedrooms should be carried out as soon as possible. Where necessary, staff should be provided with Fire Safety and Basic Food Hygiene training. An ’at a glance’ staff training matrix should be available at the Home to provide an up to date record. The monthly, unannounced audit visits to the Home, undertaken on behalf of the Registered Provider, should include interviews with staff and these should be recorded. The Service Plan for 2007/08 should be developed. Satisfaction questionnaires should be sent to service users’ DS0000019979.V340175.R01.S.doc Version 5.2 Page 25 2. 3. 4. 5. YA6 YA9 YA18 YA20 6. 7. 8. 9. YA20 YA22 YA23 YA23 10. 11. 12. 13. 14. 15. YA24 YA35 YA35 YA39 YA39 YA39 Ella Bank Road (17) relatives and care managers. Ella Bank Road (17) DS0000019979.V340175.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: 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 Ella Bank Road (17) DS0000019979.V340175.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. 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