Inspection on 07/11/06 for 2a & 2b Mayfair

This inspection was carried out on 7th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2a & 2b Mayfair 12/02/09

2a & 2b Mayfair 26/04/07

2a & 2b Mayfair 25/04/06

2a & 2b Mayfair 23/01/06

2a & 2b Mayfair 07/06/05

2a & 2b Mayfair 04/11/04

2a & 2b Mayfair 21/04/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 2a & 2b Mayfair Tilehurst Reading Berkshire RG30 4QY Lead Inspector Kerry Kingston Unannounced Inspection 7th November 2006 10:30 2a & 2b Mayfair DS0000011045.V318413.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 2a & 2b Mayfair DS0000011045.V318413.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. 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2a & 2b Mayfair Address Tilehurst Reading Berkshire RG30 4QY 0118 945 3743/4 0118 9453743 nick_debourg@hotmail.co.uk londonroad@tiscali.co.uk Milbury Care Services Limited 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) Care Home 10 Category(ies) of Learning disability (10) registration, with number of places 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2006 Brief Description of the Service: Mayfair provides twenty-four hour care to ten adults, of both sexes, with learning and associated difficulties. The home is owned by Milbury Care Services Limited. The house consists of two properties, joined internally via a corridor and has bedroom accommodation on the ground and first floors. The home is in a suburb of Reading approximately fifteen minutes from the town centre. Local shops and facilities are available within walking distance of the home. The home has its own transport and public transport is readily available. The fees range from £1,098.16 - £1,442.00. 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place on the 7th November between the hours of 10.30 am and 6.30pm. The purpose of the visit was to collect information to inform the key inspection report. Information for this inspection was collected by means of a Pre-Inspection Questionnaire and service user surveys, completed by staff on behalf of service users (nine of the ten surveys were returned) prior to the visit. On the day of the visit the inspector toured the building, observed care practice, spoke with four staff and the deputy manager. The service manager was also spoken to, briefly, by telephone. I observed and communicated, as far as possible, individually with four service users. Service users have their own methods of communication and some staff assisted, effectively, in helping the understanding between the inspector and the service users. Service user care plans and other records were looked at. The staff team have been working very hard and there are areas where care practice has improved since the last inspection. The home still lacks a permanent and settled manager but the deputy and her team have been attempting to ensure that the areas that need improvement continue to develop. Of the sixteen requirements made at the last key inspection (25th April 2006) five remain outstanding, six further requirements have been made following this key inspection. What the service does well: What has improved since the last inspection? The home makes sure that the care plans are looked at and updated so that staff can give residents the care that they need. Residents have their health needs checked regularly to make sure that everything is alright. Some new paperwork that has been introduced makes it much easier for staff to see what residents’ needs are and how they can help them. Residents are looking nice in clothes that suit them. 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 6 Staff are trained and understand how to make sure they can protect the residents from being treated badly, by anyone. The house looks much nicer, it has been painted and there is new furniture in many rooms. The carpets have been replaced with wood effect floors and it is nice and clean. Everybody can now get toilet paper when they want to. 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. 2a & 2b Mayfair DS0000011045.V318413.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 2a & 2b Mayfair DS0000011045.V318413.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 Quality in this outcome area is poor. The home is not able to meet all the needs of individual service users who are resident in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One service user, who was admitted in May 05 now has an assessment of need on his file, his Occupational Therapy assessment details the equipment he needs to enable him to sit at the dining table and use the bath. The equipment has not been provided to him and he is therefore unable to bath, he has been having a ‘strip wash’ for eighteen months, since his admission. He is also helped to eat his meals whilst sitting in the living area on the sofa. The problems have arisen because his needs were not accurately identified in the original needs assessment and there is now a debate about who will pay the £1200 for the necessary equipment. The service user’s recent review states that the home can meet most of his needs but he is not able to bath or access appropriate day care (because of cost). Another service user, for whom the placement may not be appropriate, has not been re-assessed as required at the key and random inspections in April and August 06, respectively. 2a & 2b Mayfair DS0000011045.V318413.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 and 9 Quality in this outcome area is adequate. There has been an improvement in the support staff give service users to make individual choices and decisions but further progress needs to be made. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care Plans for six service users were looked at. Care plans are reviewed by key workers on a monthly basis and external reviews have been completed throughout 2006. A new document has been developed for service users called ‘individual support requirements’, this covers all aspects of individual needs and includes choices/preferences/likes/dislikes. Risk assessments are up-to-date, existing ones have been reviewed and additional assessments completed in September 06 and October 06. Four staff spoken to described how they knew what choices service users were making and cited body language/behaviours/using the ‘communication passports’ included in care plans and encouraging signing/speech. Staff were 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 10 observed offering service users choices such as, when they wanted to be assisted with personal care, what fruit they wanted at lunch time, how much food they wanted and where they wanted to spend their time. Service users’ clothing reflected their age and taste but a staff member advised that not all service users go to buy their own clothing, key workers do it for them. One service user would choose to bathe but he is unable to (see Standard 2 Requirement 1). Only one service user was able/wanted to communicate with me and indicated that he could make his own decisions but would like to use the bath (as above). 2a & 2b Mayfair DS0000011045.V318413.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 and 17 Quality in this outcome area is adequate. Service users are being assisted to use the community and participate in activities. They are generally being supported to lead a positive lifestyle, but further development is needed, particularly with regard to staff consistency. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Activity plans for all Service users are displayed on the kitchen walls. The programmes are individual and most service users have some external activities throughout the week (this is very limited in some cases). Daily notes did not always reflect that the activities as noted on planner had actually taken place but staff confirmed that they usually do. Review notes evidenced that the home has maintained its improvement in activities, and is planning further improvement. Daily notes showed that service users are being supported to access the community and staff described how they facilitated this work and 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 12 how important they felt it was. One service user was seen to be assessed as needing more day care activities but it was noted that there was not enough funding to pay for it, this service user attends one external activity per week but he pays the thirty pounds costs himself. The home is working with care management to try to facilitate further day care and clarify who is responsible for the funding. Service users’ families are involved in their care. Some parents visit and are offered meals, individuals are assisted to celebrate family birthdays and occasions and family contact is noted on service users’ care plans. Staff were observed discussing a special family occasion with an individual who indicated how excited he was that it was his mum’s birthday and that he was buying her presents and visiting with her on that day (with 1:1 staff support). Two service users discussed/indicated their excitement at going on holiday in November, both had high support needs. Staff said that service users’ behaviour had improved as they were ‘not as bored’ and staff now reacted and interpreted behaviours (such as one person running round the house) as boredom and he wants to go for a walk, as does service users bringing their coats to staff. During the day some staff were observed engaging people in meaningful activities and communications but this was not consistent amongst all staff. This inconsistency with regard to staff approach has been recognised and had been addressed and reflected in staff meeting minutes. Ensuring that service users were engaged in activities was a major topic of discussion between the manager and the staff team. Staffs’ support for service users to make choices is improving and staffs’ ‘listening’ skills have also improved. Staff spoken to are aware of the communication methods used by service users and these are detailed in their communication plans (this was also observed on the day of the visit, although there was some inconsistency in responses by different staff members.) All toilets have toilet paper and clothing is much more individual (see Standard 7 Requirement 2). Some activities are still cancelled because of transport issues, but these occasions are less frequent. 2a & 2b Mayfair DS0000011045.V318413.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 and 20. Quality in this outcome area is adequate. The home offers reasonable personal and healthcare support but further development of the staff team and consistent care practice is necessary. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The six care plans looked at were much improved and include a document called ‘Individual support requirements’ listing all individuals’ needs and how to help them with personal care and health issues. Dates of reviews and review notes are included on paperwork. All care plans seen were up-to-date and supported by risk assessments and health records (see Standard 2 Requirement 1 re: the support needs of two of the ten service users). Equality and diversity needs are addressed in individual care plans but there remain issues around a service user being disadvantaged by his disability to make choices that others are able to (using the bath) and paying for his own day care because of his special needs. Health records are, generally, very good, showing that all annual checks are completed and the G.P and primary health care team members visit as is 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 14 necessary. There were limited behavioural guidelines on file and some health issues are not recorded as being followed up, such as an unexplained weight loss. Staff explained that they use their own skill and knowledge of the service user to help them with dealing with any behavioural issues but they were observed following guidelines in regard to personal support, for example, splitting a service user’s food into two dishes and giving a service user a choice about when he wanted support with his toileting needs. Some issues of consistency among the staff team were noted, particularly with their interactions and attitudes towards service users. Medication records seen were accurate and service users have had an annual medication review. There were no written guidelines for ‘take when necessary’ medication. Staff are observed giving medication and assessed as competent by senior staff before they are able to administer medication to service users. 2a & 2b Mayfair DS0000011045.V318413.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 and 23 Quality in this outcome area is adequate. Service users are generally listened to and kept safe but attention needs to be given to behavioural guidelines and incident reporting. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no recorded complaints since the last inspection and the Commission for Social Care Inspection has received no information about complaints; one vulnerable adults incident was reported and dealt with appropriately. Complaints have not been recorded retrospectively and no judgement could be made as to whether complaints will be properly dealt with in the future. Staff described how service users may express their unhappiness and how they might appear to be making complaints. One care plan described how an individual ‘complained’ to staff, no complaints from service users are recorded. Staff had a good awareness of vulnerable adults issues and confirmed that they had received the training. Three of the four staff spoken to gave excellent descriptions of what they would do if they had any concerns about a service user’s well being and all fully understood their responsibilities with regard to protecting them. 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 16 There were few behavioural guidelines in place with regard to how staff would deal with any aggressive behaviours and those that were in place, for two service users, note the use of physical interventions. Staff receive training in the use of physical interventions but there are no specific guidelines in place that relate to individual service users or about how and when it would be used. There are no records of the use of physical interventions and staff spoken to, including the deputy, confirmed that no incidents of ‘restraint’ had occurred to their knowledge. Incident reports show unexplained bruising on several service users but these are not followed by any analysis, record of investigation or detail of how the home will monitor or deal with future incidents. Service users’ monies are well recorded and checked to ensure they are correct at every shift handover (between seniors). The organisation now provides receipts to service users for any large expenditures but it is not clear how much they pay for transport costs (as contributions are now taken directly from service users’ money.) 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 17 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 and 30. Quality in this outcome area is good. There have been major improvements in the environment for the service users but there needs to be some thought given to how to assist one service user to maintain a reasonable level of comfort in his private space. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The house has all new flooring downstairs, it has been changed from carpeting to vinyl wood effect floors, which make it look less homely but it is very clean and hygienic. The home has been almost completely redecorated, including bathrooms and bedrooms. All service users’ bedrooms were seen and all but one were individualised and personalised, with new bedding, soft furnishings and bedroom furniture. One room had no personal belongings or soft furnishings and the built in wardrobe was locked, a staff member explained that the individual had a behavioural issue, which resulted in the destruction of any items or soft furnishing in his room. There were no records of guidelines 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 18 or attempts to help the service user to minimise the impact of this behaviour, or of any efforts to design an environment that would be robust enough to withstand these difficulties. The home was very clean, hygienic and well maintained. The delivery of more bedroom and living room furniture is awaited. Two service users indicated that they were very happy about the new things in the home and the decorating. 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 19 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 and 36. Quality in this outcome area is good. The staff team is quite new but the home is working very hard to develop the team, as quickly as possible. Any areas where there are difficulties are recognised and addressed by training and direct supervision. There are good training opportunities to enable the staff to meet the individual needs of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a minimum of six staff during daytime hours. There are twelve full time and thirteen part time staff, the home use very few agency staff and cover any necessary shifts with bank workers known to the service users. There have been five new staff appointed in the last three months, eleven of the staff team have been working in the home for over a year. The staff team is much more consistent although there can be up to twenty-five people covering the weeks shifts. 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 20 Staff spoken to have a good knowledge of the needs of the service users. A written induction is completed by all new staff who then pursue Learning Disability Framework Award basic training. Staff complete the award and are then able to apply for professional N.V.Q. training. Five of the current staff team have completed N.V.Q. 2 or above and six are pursuing their N.V.Q. Regular staff meetings are held and the minutes evidence good content with discussions about staff consistency with regard to practice and activities, any problems staff or service users are experiencing and information giving, as appropriate. Service users participate in the staff meetings and their reactions to certain topics/discussions are noted. Supervision takes place but is not completely up-to-date as the manager has been absent, for an extended period. Senior staff are working hard to try to address this. Supervision notes address attitudes and practice of individual staff. Staff commented that the ethos of the home is now much more open, they feel comfortable to discuss any problems with each other and with senior staff, this was mentioned as an area of improvement by three staff. The staff team is developing and those spoken to were very enthusiastic and keen to pursue training and new ideas that would benefit the service users. Staff confirmed that there are plenty of opportunities to access basic and professional training and that they are encouraged to do as much training as possible. Recruitment records of the two newest staff members were complete and contained all the necessary information. 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 21 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): 37,39,40 and 42. Quality in this outcome area is adequate. The home is being adequately managed, in difficult circumstances. Long term management arrangements need to be made as soon as possible to ensure that the home maintains its impetus for improvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has not registered with the Commission for Social Care Inspection, she has been on extended leave since the end of September, after being in post for approximately one month. The deputy home manager has been managing the home in the absence of the manager, with the service manager visiting approximately twice a month. The service manager said that the organisation was thinking about how to manage the home and what 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 22 management support it needed. The staff team are assisting the deputy to adequately manage the home, but some staff said that they were concerned that they did not know what the management arrangements were to be in the long run. They commented that staff motivation was currently high, there was good progress and improvements in the home. They felt that they needed robust management arrangements to continue with this progress. An annual development plan was displayed on the office notice board, it set out all the improvements the home is trying to achieve. Regulation 26 visits are completed regularly. The deputy manager had no knowledge of the quality assurance system and was unable to locate any paperwork. All Health and Safety maintenance checks are complete and staff have regular health and safety training. The only issue that relates to service users’ safety is the analysis and action taken when incidents have been reported (see Standard 23 Requirement 5). 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 23 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 2 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 3 X 3 X 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 24 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 YA2 Regulation 14 Requirement To evidence that the home is able to meet the assessed needs of new service users. (Outstanding timescale 01/07/05, 01/04/06, 24/10/06) Carry out reassessment of a service user to see if the home is still meeting their needs. (Outstanding timescale 24/10/06) To ensure the home ascertains the wishes of service users and enables them to make as many decisions for themselves as possible. To ensure that activity programmes take place (internal and external) as scheduled. To review the practice of a service user paying for his day care activities. To ensure that the complaints procedure is adhered to. (No complaints received since last inspection.) (Outstanding timescale 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 25 Timescale for action 01/12/06 2. YA2 14 01/01/07 3. YA7 12(2)(3) 01/03/07 4. 5. 6. YA12 YA12 YA22 16(2)(n) 16(2)(n) 22 01/02/07 01/12/06 01/03/07 01/04/06, 25/08/06) 7. YA23 13(6)(7) To develop individual guidelines to enable staff to safely assist service users to control/minimise any aggressive behaviours. To ensure incident reports are analysed, investigated and any necessary action is taken to minimise, prevent the risk of reoccurrence. To develop strategies to assist one service user to have adequate private accommodation so that he is able to maintain his privacy and dignity (as far as possible.) The Manager should submit an application to be registered. (Outstanding timescale 25/08/06) To complete the quality assurance system. (Outstanding timescale 01/09/06) 01/01/07 8. YA23 13(6) 01/12/06 9. YA24 12(4)(a) 23(2)(e) 01/01/07 10. YA37 9 01/02/07 11. YA39 24 01/02/07 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 YA19 YA20 YA23 Good Practice Recommendations To ensure that staff have a consistent approach to the care and health needs of service users. To develop guidelines to ensure there is consistency when administering medication prescribed to be taken ‘as necessary’. To advise service users of their individual contribution to transport costs. 2a & 2b Mayfair DS0000011045.V318413.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 2a & 2b Mayfair DS0000011045.V318413.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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