Inspection on 31/12/07 for 185 Passage Road

This inspection was carried out on 31st December 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

185 Passage Road 17/02/09

185 Passage Road 03/04/07

185 Passage Road 10/04/06

185 Passage Road 15/09/05

185 Passage Road 21/04/05

185 Passage Road 13/09/04

185 Passage Road 27/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 185 Passage Road Brentry Bristol BS10 7DJ Lead Inspector Andrew Pollard Unannounced Inspection 31st December 2007 09:20 185 Passage Road DS0000026543.V353369.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 185 Passage Road DS0000026543.V353369.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. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 185 Passage Road Address Brentry Bristol BS10 7DJ 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) 0117 9509586 0117 9699000 www.brandontrust.org The Brandon Trust Mr Ronald Graham Hepworth Care Home 7 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (2), Mental disorder, excluding of places learning disability or dementia (3) 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate male persons only May accommodate persons aged 40 years and over May accommodate persons with a Learning Disability and additional Mental Disorder 3rd April 2007 Date of last inspection Brief Description of the Service: This home is registered to accommodate 7 male residents with a learning disability. The current resident group have a variety of complex needs whose ages range from 43-88 years. The Registered Providers for this home are the Brandon Trust. This single level home is situated on Passage Road and is close to local amenities. There are local bus stops providing easy access to the city centre and to Cribbs Causeway and its shopping facilities. The home blends easily into the local community and is in keeping with the neighbouring properties. The home is fully accessible to the current resident group providing ground floor accommodation. However a ramp is needed to ensure full access to the grounds for residents whose mobility has deteriorated. There is a large well-kept garden mainly laid to lawn with fruit trees. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced ‘Key’ inspection carried out on this home. The purpose of this visit was to review the requirements previously set and review care practice in the home. All information received about the service was taken into consideration when carrying out the inspection. A Quality assurance assessment was sent to the home, as were resident feedback questionnaires. Information gained from these has been used to inform this report. Questionnaires were also sent to relatives of the residents and to their General Practitioner. The inspector spoke to 2 residents and 2 staff members who provided information for the compilation of this report. Documentation was examined relating to residents and to the general running of the home and health and safety issues. What the service does well: What has improved since the last inspection? The residents are receiving adequate information about the care they will receive and have up to date contracts detailing the terms and conditions of their residency and what they can expect from the service. The statement of purpose was updated and a copy sent to the Commission. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 6 All staff received formal supervision at least 6 times a year and staff meetings take place. What they could do better: Keep care plans under review. Ensure staff receive appropriate training for the work they perform and are updated in training considered compulsory. All staff should be updated in Adult Protection training to enhance their awareness about issues related to abuse. Revise care plans with the residents and including professional’s family and advocates as appropriate to reflect the changing needs and aspirations and changes are recorded and actioned. Introduction of the “OK Health Check” or similar to help develop health action plans. Clean or replace the lounge carpet. Consider redecoration of communal areas and replacement of some old carpeting to make the house more homely. Ensure that all residents have ease of access to the rear garden by path or ramp. The garden decking area be provided with a shelter For the use of smokers in wet weather. Adult Protection training to be added to the rolling programme of compulsory training provided and that all staff attends a training session. Provide training relating to the needs of the resident group. When training is provided regular or bank staff fill in for the night shift to enable night staff more opportunity to attend. Staff should have an annual appraisal to review performance and draw up personal development plans. Ensure risk assessments are reviewed regularly and revised following a residents annual person centred review. The manager has the full eight supernumerary hours rostered each week to give attention to his managerial and administrative functions. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 7 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. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are issued with living agreements and the terms and conditions of their stay at 185 Passage Road. The statement of purpose and service user guides provides helpful information. EVIDENCE: There have been no admissions to the home since the last inspection in April and the resident group remain stable. The statement of purpose and accompanying service user guide are being reviewed and updated. The documents had been written in a straightforward way and were easy to understand. All residents are admitted via Social Services through the placement team and the community nursing learning disability team. A prospective resident has been identified to fill a vacancy at the home. The manager has assessed their needs and the home’s ability to meet the needs, and gathered relevant information although a final decision is yet to be made. Contracts were seen and where possible signed by the resident or their representative. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 10 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): 6,7,8,9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents would benefit from more frequent reviews of their care plan and risk assessments to ensure the risk identified and action taken to support remains current. Residents are able to make their own decisions relating to everyday life. EVIDENCE: A key worker system is established in the home. There were care plans in place, which aimed to address the physical, mental, and social needs of the person using a person centred approach. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 11 Care plans were examined and it was noted that some were in urgent need of review. Several care plans had been written in 2005 and no significant rewrites had taken place. The planning for life folders were not all up to date and the Person Centred Planning sections were often blank. The folders contain templates that, if well completed would benefit the residents in that a comprehensive collection of information would be available to offer support. All residents have individual risk assessments in their files. There was information included about any potential risks and risk behaviours that may be exhibited and there management. Any restrictions of liberty or choice are supported by a risk assessment and care plan. Risk assessments were often not fully reassessed on a regular basis. It was also agreed with the manager that following the annual IPP and health review the care plans would be rewritten and more substantive evaluation/reviews take place and be recorded rather than a repeated “no change” being entered every time. Daily records and monthly summary notes are made. The inspector discussed with the manager the need to back file old information and keep the files as current working documents. Residents confirmed through comment and via the surveys that they can make their own decisions and choices within their everyday live. Some residents that are less able to communicate are advocated for by relatives or key workers in the decision-making processes. Records of residents meetings show that some residents have very clear ideas and concerns and suggestions about home matters. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 12 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): 12,13,14,15,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to have a variety of activities. The residents have a choice of the food they eat and a balance diet. EVIDENCE: At the last inspection it was noted that there had been an improvement in activities for residents who had little or no day care services. A quick view sheet has been put in place to record all activities undertaken to ensure an adequate review and inform staff at a glance if more or less input is needed. Some residents had an activity most days but others still have very few this is in part the residents choice and in part a lack of staff resources particularly in the afternoons where there are often only two staff on duty. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 13 The residents have previously said that they would benefit from having a minibus, as it would be easier to go out, as at present there is only a car. There was some indication in the last report that this was being taken forward by the Trust, to date there has been no progress with this plan. All residents contribute towards the cost of transport in relation to their use. Day care workers were observed working with specific residents. Positive relationships had been formed and residents enjoyed their sessions. There is good input from ‘choices for learning’ and information in place regarding likes and preferences. Three residents have part time paid employment. All bar two residents (by choice) had holidays last year, which were a success. There are planned holidays to Blackpool or Butlins this year. Most residents have family contact to varying degrees and the staff welcome any input or feedback they receive. One resident uses email to maintain contact with family. There are no residents with particular cultural or faith needs. No one requires a special diet. The residents are involved with menu planning and the records show that food is varied and offers a balanced diet. Whilst there are three residents in the home that smoke there is a policy in place whereby residents should smoke outside on the decking but this is not practical in cold or wet weather as there is no shelter The manager and residents through the Trust forum have raised this issue. To date there has been no progress. It was suggested that as a temporary measure that the porch area could be used in poor weather until better arrangements are made. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 14 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. Residents receive support in a way that suits them and referrals are made to other healthcare professionals to ensure health care needs are met. Residents are protected by a medication policies and procedures and PRN medication is administered appropriately. The staff team supports the resident’s health needs but this could be improved through thorough health action plans and reviews. EVIDENCE: All the residents are registered with a local GP and are under the care of a consultant psychiatrist who visits periodically during the year and conducts medication reviews. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 15 Residents are able to access dental and optical services either in the home or community. The GP make referrals as required for specialist services. One resident is currently under the care of a district nurse. Residents have health care information and records in their files. However the amount of detail recorded and rigour of reviews and evaluations vary. Some residents have an outline health action plan but he overall standard of this provision is minimal. There are proper arrangements in place for residents to access medical, dental and optical services as required. Storage of medication is satisfactory. Medication administration record sheets, receipts and disposal records were examined and found to be in order. PRN medication was noted to be used appropriately in line with specific plans of care and significantly used less than previously due to good management of challenges presented by some residents. At present no residents are assessed as being safe to self medicate. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 16 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 adequate This judgement has been made using available evidence including a visit to this service. The home has good arrangements in place for making sure that individuals are able to make complaints. The residents would be better protected if the home had up to date Local Authority protection and reporting procedures and the staff team were more regularly trained in the implementation of adult protection procedures. EVIDENCE: Policies and procedures were seen to be in place in relation to complaints including a simplified format for residents. The complaints book showed that residents can and do make complaints and these are acted upon by the staff. There have been no complaints about care since the last inspection. The most significant complaint (still outstanding) relates to the lack of shelter in the garden for the use of residents who smoke. To date the Trust has taken no action on this matter. No complaints were made through surveys or on the day of the visit. There was no evidence that staff have any on going training in relation to adult protection procedures other than during induction. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 17 The manager had made enquiries about training updates but had not pursued the matter. The home had a 2005 version of the Local Authority “No secrets” procedures the manager is to acquire the most recent Adult Protection policy when booking training. The records in relation to resident’s accounts and the safe keeping of personal allowances were up to date and in order. Balances are checked regularly and receipts kept with the ledger sheets. The Trust has recently carried out an internal audit and there are no outstanding matters. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 18 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): 24,25,27,28,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All areas of the home meet the needs of the current resident group. There is no flat access to the garden and no shelter for smokers. The garden is not easily accessible to all residents. The home is clean and tidy. EVIDENCE: At the last inspection it was strongly recommended that a ramp be installed for ease of access to the rear garden. This will meet the changing mobility needs of residents. The manager confirmed that the Brandon Trust has agreed the 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 19 installation of the ramp or extension of the path from the side of the house to the rear garden. However to date no action has been taken. There is no cover over the garden decking to facilitate outside smoking for residents in cold or wet weather. This matter has been raised by staff and residents with the Trust; to date no action has been taken. It was suggested that the porch area could be used as a temporary smoking area in bad weather. The house although clean and tidy is a mixture of homely and institutional in its appearance. All the doors were blue and the corridors and stairs looked bare and hospital like with old fashioned blue Flotex style carpet. The lounge was homely, however the carpet is heavily stained and requires cleaning or replacement. The resident’s rooms were well decorated and personalised. Some bedrooms also have blue flotex style carpet. The standard of furnishing is good. The home was clean and in general good order. The hot water supply in the home is unreliable and often fails. A heating engineer was in the home on the day of the visit to try to rectify the problem. At the top of the house is the staff sleep in room, which doubles up as an office. Also in this room are all the medication cabinets. Many files and records are kept in the dining area, which is not ideal as it impinges on resident’s space. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 20 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): 32,34,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is adequately staffed with experienced staff. Staff training needs to be improved. Staff work hard to meet residents’ complex needs. The staff are supervised. Appraisals have not taken place. There is a robust recruitment procedure in place that protects vulnerable adults. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 21 EVIDENCE: The Trust has a robust recruitment procedure in place that protects vulnerable adults. All personal files are now held at the head office, which include completed application forms, two references and criminal records checks. All new staff completes a Trust induction programme including the Learning Disabilities Award Framework. There has been some staff turnover in the home and various staff have been slotted in from other homes that have closed. The manager considers these staff do have the skills and experience needed to work in the home. The consistency of staffing is important to the wellbeing of the residents and maintaining the strategies of care that prevent challenging incidents and tensions in the home. Bank staff have been used to cover gaps in the rota and where possible continuity is maintained. The manager considers that the staff work well as a team and supported one another. Due to the resident vacancy the manager has not been working the full allocation of 8 supernumerary hours, which is reflected in some of the paperwork inadequacies, reflected elsewhere in this report. For the same reason there has on occasions only been two staff on duty in the afternoons, which has implications for residents activities. There was little evidence that the current staff team had completed much training in the last twelve months. The Trust expects all staff to remain updated in the following areas; food hygiene, load handling, first aid, health and safety, fire safety and adult protection. The training records showed very limited updating for staff in all these areas apart from fire safety. The manager felt that the records may not be up to date and was not sure what the frequencies for up dates were supposed to be. The manager has done minimal clinical updating as a nurse. Five staff have NVQ level 2 qualifications and two people have level 3. There are staff meetings periodically through the year for which records are made. The manager confirmed that the staff team do receive supervision at the required frequency but no appraisals have been carried out. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 22 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): 37,39,42,4 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents have not benefited from a consistent management approach to the home by the home manager or service development manager. Staff endeavour to run the home for the benefit and well being of the residents. There are appropriate arrangements in place to service and repair plant and equipment. The health and safety of residents is promoted and there are adequate policies and procedures in place to assist staff members. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 23 EVIDENCE: Regulation 37 notices had been submitted for a recent residents hospital admission and a death. The Service Development Manager (SDM) carries out monthly ‘regulation 26’ visits to offer support. Copies of the reports are sent to the CSCI. However there were a number of requirements and recommendation from the last inspection in April and it was not clear that there had been sufficient supervision or a planned approach to deal with these matters numerous of which remain outstanding. There have been several changes of service development manager in about a year and the manager only formally took post in August. The manager has many years experience of managing a similar home and has now completed the CSCI fitness assessment process. The manager is confident that good progress can be achieved in a relatively short period of time to meet the requirements. The Commission will carry out a random inspection in the coming months to assess progress. Relatives comments about what the home did well included,” They provide a homely environment, the staff genuinely care about my relative” and “I feel the service has supported my relative and he is given as full a life as is possible”. Electrical and gas safety inspections have taken place. The fire logbook was up to date and in order. The specialist bath has been serviced. Water temperatures are monitored. The home’s certificate of insurance was displayed, as was the registration certificate. The home has Health and Safety policies and procedures put in place by the Brandon Trust to safeguard residents and staff. Policies are adopted and adapted to suit the home. Unless identified throughout these policies were up to date. Records of a confidential nature were kept in a lockable facility. Quality assurance programmes or outcomes were no reviewed on this occasion. 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 24 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 x 32 2 33 3 34 x 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 x LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 2 x x 3 3 3 2 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 25 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. 2. Standard YA6 YA35 Regulation 15.2 (b & c) 18.1 (c) Requirement Keep care plans under review. Ensure staff receive appropriate training for the work they perform and are updated in training considered compulsory. All staff should be updated in Adult Protection training to enhance their awareness about issues related to abuse. Timescale for action 01/04/08 01/05/08 3. YA23 13.6 01/04/08 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 Revise care plans with the residents and including professional’s family and advocates as appropriate to reflect the changing needs and aspirations and changes are recorded and actioned. . Introduction of the “OK Health Check” or similar to help develop health action plans. Clean or replace the lounge carpet. DS0000026543.V353369.R01.S.doc Version 5.2 Page 26 2. 3. YA19 YA24 185 Passage Road 4. YA24 Consider redecoration of communal areas and replacement of some old carpeting to make the house more homely. Ensure that all residents have ease of access to the rear garden by path or ramp. The garden decking area be provided with a shelter For the use of smokers in wet weather. Adult Protection training to be added to the rolling programme of compulsory training provided and that all staff attend a training session. Provide training relating to the needs of the resident group. When training is provided regular or bank staff fill in for the night shift to enable night staff more opportunity to attend. Staff should have an annual appraisal to review performance and draw up personal development plans. Ensure risk assessments are reviewed regularly and revised following a residents annual person centred review. The manager has the full eight supernumerary hours rostered each week to give attention to his managerial and administrative functions. 5. 6. YA24 YA23 7. YA32 8. 9. YA36 YA9 10. YA37 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 185 Passage Road DS0000026543.V353369.R01.S.doc Version 5.2 Page 28 - 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!