Inspection on 29/10/07 for 26 Cheddar Grove

This inspection was carried out on 29th October 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

26 Cheddar Grove 14/02/07

26 Cheddar Grove 07/02/06

26 Cheddar Grove 21/11/05

26 Cheddar Grove 18/02/05

26 Cheddar Grove 29/09/04

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 Cheddar Grove 26 Cheddar Grove Bedminster Bristol BS13 7EN Lead Inspector Sarah Webb Unannounced Inspection 29 October 2007 09:00 th Cheddar Grove DS0000020273.V350226.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 Cheddar Grove DS0000020273.V350226.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. Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cheddar Grove Address 26 Cheddar Grove Bedminster Bristol BS13 7EN 0117 9077214 0117 9077214 colin.westwood@brandontrust.org www.brandontrust.org The Brandon Trust 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) Mr Colin Richard Westwood Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (7) of places Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Staffing Notice dated 28/03/1994 applies Manager must be a RN on parts 5 or 14 of the NMC register May accommodate up to 7 persons aged 40 years or over, with Learning disabilities. 14th February 2007 Date of last inspection Brief Description of the Service: Cheddar Grove is a large house set in a quiet area of Bedminster Down on the outskirts of Bristol. It has good links with local amenities, shops, pubs and a post office, which are all within walking distance. The house has seven bedrooms, four of which are on the ground floor. There is a large back garden overlooking a school field. The home has qualified nurses on duty at all times and provides a service for adults with learning difficulties and mildly challenging behaviour, some of whom are non amublant. The home has mobility aids and all parts of the home are accessible. The aim of the home is to provide total support for the people using the service in all aspects of their lives. People are encouraged to develop self-confidence and life skills. People are taken on various holidays, outings and have links with local colleges and day centres. The fees for the home are £1231 per week. Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key Unannounced Inspection that took place over one day. A safeguarding meeting was also attended at the home at a later date. People using the service and several of the care team were met during the visit. The Manager was unavailable but discussion was had with an assistant manager who helped with the inspection process. This process included viewing records in relation to admissions, care and support plans, risk management, the administration of medication, and the management of behaviours and interventions. Further information was also provided through the homes Annual Quality Assurance Assessment. A tour of the home was undertaken and interaction between staff and people was observed during a miday meal. Surveys were received by 4 relatives, and with two from Health Care Professionals. Feedback was generally very positive in the care and support offered to people. As a result of this inspection two requirements and 3 recommendations have been made. What the service does well: What has improved since the last inspection? The home has followed appropriate procedures in trying to safeguard the people living at Cheddar Grove from others that challenge. Safeguarding strategy processes have been implemented and a protection plan put in place. Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 6 Staff have attended training in the protection of vulnerable adults. People using the service benefit from their plans of care being reviewed on a regular basis. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cheddar Grove DS0000020273.V350226.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 Cheddar Grove DS0000020273.V350226.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): 2, 3, 4, & 5 Quality in this outcome area is good. Satisfactory arrangements for people coming into the home make sure their needs are met. When needs cannot be met action is being taken to find a more suitable placement. Contracts are not set out in an understandable format to help people understand the conditions of their stay. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care files contained assessments of peoples needs including copies of those completed by placing authorities. Care plans also identified how staff should support people. The home currently has a vacancy and there has been interest shown by several placing authorities. An assistant manager, David Jones, said the manager has been to visit a propective person wishing to move to the home so that they can be sure that their needs can be met; as yet the vacancy has not been filled. The admissions process also includes visits to the home that are arranged prior to people moving according to their needs, and it was indicated that some people may need a longer time in moving whilst others may need to move Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 9 quicker. This identifies that the home takes an‘individual’ approach to each person. It was identified in the returned Annual Quality Assurance Assessment(AQAA) that the home meets the changing needs of individuals. This was evident through an individual moving from a first floor bedroom to a more appropriate ground floor bedroom that was vacant. It was evident through discussion with staff and documentation that this move met their needs better . However although it was evident that staff are supporting this person to the best of their ability and within the resources, there have been other aspects of their needs that have changed due to their behaviour having escalated. A more suitable placement is urgently being looked for but this is not easy due to their complex needs. This is recorded fuller in the text of Standard 22. Contracts seen remain unchanged;Mr Jones said that the organisation is in the process of developing an accessible format would help people to understand the terms and conditions of their stay better. Cheddar Grove DS0000020273.V350226.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, & 9 Quality in this outcome area is good. People are involved in making decisions about their lives and in the planning of their care. Risk assessments help people to take risks more safely but there are still some areas that need to be developed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans looked at indicated that a person centred approach helps staff to ensure that individualised support is offered. Information identified peoples preferences and how people wish to be supported. A requirement about developing a person’s care plan and producing guidelines for staff dealing with challenging behaviour has been partly met. It was evident that information in a person’s care plan had improved and guided staff in relation to when they may be challenging. However staff spoken with said the unpredictability and daily changes of the behaviour was a concern and that there are specific processes that are followed when using the homes vehicle. This must also be included in the care plan and a risk assessment completed. Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 11 Care files identified that keyworkers complete monthly summaries of peoples general care, welfare and activities attended. A requirement has been met for peoples care to be reviewed; 3 monthly reviews are carried out and this was evidenced through records. The diary contained set dates for future 3 monthly reviews. House meeting records showed that staff encourage people to speak up and voice their opinions and make decisions about various aspects of life in the home. Risk assessments were detailed and had been reviewed meeting a requirement. The home is planning to involve families in their relatives care through the development of person centred planning. This was an area that was identified through surveys returned by relatives. They felt the home only sometimes involved them and kept them informed. One survey said they would like to be more involved and that this is an area that the home could improve. The overall consensus from returned surveys from families stated that they were happy with the support offered to their relative. One survey stated ‘ The care is excellent and the needs of the residents at Cheddar Grove vary – in our opinion each individual is cared for very well.’ Cheddar Grove DS0000020273.V350226.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, 15, 16, & 17 Quality in this outcome area is good. People who use the service are able to make choices about their lifestyle, and supported to develop their life skills. People benefit from differing social, educational, and recreational opportunities. People benefit from meals that offer a nutritious and varied choice and encourage healthy eating options. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Through observation of peoples movements during the day, and discussion with staff and people it was evident that they have varied and individual lifestyles. Structured timetables of activities are followed, including attendance at day centres, hydrotherapy, college and activities with the staff. Arrangements were being made for an individual to go out to an evening concert in Bristol; people were seen going out in the homes vehicle, listening to music and watching television. Records of activities showed that people go to different places for a variety of activities. Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 13 There is extra staffing to support an individual on a 1:1 basis and although the roster indicated that there should be 4 staff on duty, on this visit there were only 3. However a staff member did take the individual out in the homes vehicle following their timetabled activities. Mr Jones said that the home has good relationships with families and that they supported an person in going on holiday with their family. This proved very successful. People have had a barge holiday and stayed in holiday lodges in Wales. One person was also supported by two staff on an individual holiday. A survey returned by a family member said ‘The home considers the welfare of all ensuring their happiness and giving them as full a life as possible taking them on holiday that are well suited’ Menus seen were varied and nutritious. People are involved in making decisions about their choices of food and it was evident that staff have a good understanding of their preferences. Cheddar Grove DS0000020273.V350226.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 good. People are supported to lead healthy lifestyles with their healthcare and personal needs being monitored well. People are treated with respect and are safeguarded by the home’s medication practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Personal healthcare plans showed how people wish to be supported so that peoples healthcare needs are assessed and met. It was evident that the home works well with other professionals. People are referred to appropriate healthcare specialist if needed. Records indicated that people are supported through professionals including the dentist, dietician,, physiotherapist and occupational therapist. An epilepsy assessment for an individual was carried out by the Community Learning Disability Team with working protocols set in place for staff to support them. Due to an individuals healthcare needs changing significantly, the responsibility for their care has changed to Continuing Healthcare (National Health Service); A comment card received by a consultant psychiatrist indicated that the home supported people well with their healthcare needs. Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 15 Health action plans contained information showing that people have an annual health check and that their medication is reviewed regularly. An individual readmitted to the home after being discharged from hospital was supported appropriately by nursing staff prior to his death. The assistant manager said that agreements were in place with healthcare specialists and community nurses had called weekly and had given staff advice. The procedures and systems for administration, storage and disposal of medication were checked to monitor if the systems are safe. The medication administration charts of several people were looked at. These were clearly written and contained signatures of the staff administering the medication. Photographs of people were kept with each record to help ensure medication is administered correctly to the person named on the chart. There were guidelines for giving “as and when required” medication. These showed what the medication should be used for and the possible side effects. Stock checks take place on a weekly basis and all medication is signed in and dated. Medication that was no longer required was being returned to the pharmacist. The qualified nursing staff are responsible for administering medication and have attended training in the monitored dosage system. Staff training records showed that some staff have attended training in first aid, manual handling, dementia mapping, and epilepsy. Not all training records had been updated with current training and updates attended. Cheddar Grove DS0000020273.V350226.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. People benefit from effective systems for complaints but cannot be confident that they will be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Relatives surveys received showed that they know how to complain and that the home responds if concerns are raised. One survey also indicated that they had no complaints. There is a protocol that supports people living in the home and staff if allegations of abuse are made. The protocol includes following safeguarding procedures and who to contact . Copies of the complaint procedure were available for people in their bedrooms in an easy to read format. Peoples’ views and concerns are listened to and acted on through house meetings and on a 1:1 basis. The complaints log had no new complaints recorded; however Mr Jones said that he was concerned that people were not complaining any more about the challenging behaviour of an individual as the aggressive actions have continued with people being hurt. It is evident that this persons placement has broken down due to their behaviour escalating and presenting aggressive behaviour. This has affected the other people living at the home and the staff. Since the last inspection, we have been notified of 19 incidents of violent and aggressive behaviour towards people living at the home and staff. Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 17 However a requirement has been met for the home to make a referral to Bristol City Council to develop a strategy of support, involving other professionals in the protection of people living in the home. Training records identified that staff have attended training in protection from abuse. Regular meetings have taken place through safeguarding procedures and minutes of meetings showed a protection plan is in place to help ensure the safety of other people living at the home. Staff spoken with said that they follow a consistent approach in dealing with incidents and records showed how the person should be supported. This included what is likely to upset the person and how staff should deal with it. Despite this people have still been at risk. This is not acceptable and measures are now being taken to protect people living in the home and meet everyone’s needs. A requirement has not been made as action is being taken. Cheddar Grove DS0000020273.V350226.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, 29 & 30 Quality in this outcome area is good. People live in a homely, safe and clean environment that meets peoples care needs; there are still some areas that need to be redecorated as identified through the homes refurbishment plan. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 26 Cheddar Grove is situated in a residential area to the South of the city of Bristol. The home is in keeping with the local neighbourhood and has good access to public transport. The home is accessible to people who have a physical disability. A tour of the home was undertaken. People have single bedrooms. Those seen had been personalised by the individual. There is a stair lift to access the first floor bedrooms. There are also bedrooms on the ground floor. There are two lounges that are homely and decorated to a good standard, and a dining area and kitchen. Both Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 19 lounges were in use during the visit and people were seen moving around the house freely. Since the last visit the home has been refurbished and redecorated. Carpets have been replaced and a bathroom has been redecorated. The refurbishment programme was to include the redecoration of another bathroom and the dining room, but this has not taken place as yet. The home has a number of aids to assist people with their personal care and mobility including hoists. Certificates showed that theses are routinely maintained. Radiators are fitted with guards; water is temperature controlled in bathrooms but not in peoples sinks in their bedrooms. Mr Jones was advised to risk assess the vulnerability of people using hot water from their sinks. Windows are fitted with restrictors for safety. Surveys received from families stated that ‘‘the home is clean and is beautifully run’ and ‘the home is spick and span and always looks lovely.’ Cheddar Grove DS0000020273.V350226.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): 31, 32, 33, & 35 Quality in this outcome area is good. Staff in the home are skilled and in sufficient numbers to support people. Some staff have received relevant training to meet the needs of people. Staff are supported in their role through formal supervision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are sufficient numbers of staff employed at the home. They are an effective staff team consisting of 5 qualified nurses and 3 support staff. A vacancy has been recently filled but there are still hours that are vacant that are covered by both staff employed at the home and regular bank staff. Several of the staff spoken with demonstrated a good understanding of their role and responsibilities. New staff attend corporate induction which includes attending training including fire, food hygiene and abuse. Staff complete the Learning Disability Award Framework before doing a National Vocational Award in care. Almost all staff have completed this qualification. This is good practice. Some staff training records did not show all the training that staff had attended. The records showed that some staff have attended training in understanding differences, and sharing the challenge. Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 21 It was not clear whether all staff had attended training in supporting people that challenge. It was clear that staff knew how to support people who can be challenging. However it would be good practice for staff to receive formal training in this area. The staffing records are not kept on the premises but held at the Brandon Trust Headquarters. It is expected that we will be completing inspection of the personnel department to view staffing records. Mr Jones said the manager supervises the qualified nurses, and then they in turn supervise the home support workers. Staff spoken with said that they have received supervision regularly; signatures are taken from staff when they had received their supervision session. Relatives surveys received made comments such as ‘the staff have the right skills to do the job’ and ‘staff are friendly and helpful.’ Another survey stated that ‘Cheddar grove is excellent and all the staff very caring. Cheddar Grove is a real home’. Cheddar Grove DS0000020273.V350226.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 Quality in this outcome area is good. People benefit from leadership that promotes an open and inclusive style of management and in which peoples views are acted on. There are processes to monitor health and safety to ensure people are safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager, Mr Westwood, has been on a period of extended leave but has now returned to managing the home. Although he was unavailable on the day of the visit, he was contacted and given feedback from the inspection. Staff said that they were pleased the manager was back but also said that things had been managed well whilst he was away. It was evident from speaking to staff that they and the people living in the home get involved in the running of Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 23 the home. Staff also said that the team work well together and voluntarily attend team days in their spare time. Brandon Trust has procedures for the monitoring of the service through quality assurance. All staff are aware and are involved in these processes. Monthly unannounced visits to the home are carried out by the organisation, with copies of visits sent to us. Fire records evidenced that the home has completed a fire risk assessment identifying any fire hazards and how to keep the home safe. Fire equipment checks were taking place and all staff also undertook fire drills and training. Other records such as the servicing of the hoists, and portable appliance testing, showed there are health and safety systems in place helping to ensure people are protected. The certificate of employer’s liability was displayed with the registration certificate. Cheddar Grove DS0000020273.V350226.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 x 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 x 35 2 36 3 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 3 3 x 3 x x 3 x Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 25 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 (1) Requirement Include in an individuals care plan how they are supported when going out in the homes vehicle so that they and other people using the vehicle are helped to be kept safe. Risk assessment an individual going out in the homes vehicle so that they and other people using the vehicle are helped to be kept safe. Timescale for action 09/11/07 2. YA9 13 (4) 09/11/07 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 YA5 YA35 YA35 Good Practice Recommendations Ensure peoples’ contracts are user friendly. Update staff training records with current training attended Staff to receive training in supporting people that challenge. Cheddar Grove DS0000020273.V350226.R01.S.doc Version 5.2 Page 26 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 Cheddar Grove DS0000020273.V350226.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. 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