Inspection on 25/07/05 for 30 Broad Lane

This inspection was carried out on 25th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

Other inspections for this house

30 Broad Lane 19/08/08

30 Broad Lane 24/08/07

30 Broad Lane 06/06/06

30 Broad Lane 16/01/06

30 Broad Lane 21/02/05

30 Broad Lane 17/05/04

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

CARE HOME ADULTS 18-65 30 BROAD LANE Upper Bucklebury Nr Reading Berkshire RG7 6QJ Lead Inspector Steve Webb Unannounced 25 July 2005 @ 10:15 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 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 Stationary 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. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 30 Broad Lane Address Upper Bucklebury Nr Reading Berkshire RG7 6QJ 01635 871191 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Milbury Care Services Limited Care Home 6 Category(ies) of Learning Disability LD registration, with number Learning Disability over the age of 65 years of places LD(E) Physical Disability PD Physical DIsability over the age of 65 years PD(E) 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21/02/05 Brief Description of the Service: This service provides a ‘home for life’ to five residents, of both genders, with learning and some physical disabilities. It is operated by the Milbury group. The service aims to enable service users to live a fulfilled life underpinned by “The Five Accomplishments of Ordinary Living” (John O’Briens). The home operates within a two storey detached house in Upper Bucklebury, having been relocated from its previous location in Lambourne, in Autumn 2002. The house is located on a main road but is set back from this, and has a good sized rear garden. The unit has a newly appointed manager, who commenced in post two weeks before this inspection. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on 25/7/05 between 10.15am and 2.30pm. The newly appointed unit manager, in post for two weeks, was present. The inspection included discussion with the manager, examination of records and files, brief discussion with staff on duty, inspection of the building and some contact with service users. The inspector had lunch with service users. The list of previous requirements were also re-examined to identify where these had been addressed. More than half had been addressed, with some also having been partially dealt with. However, the deficiencies identified in the legionalla survey had yet to be addressed. This was of some concern as it relates to health and safety. It was acknowledged that the manager had only just been appointed, and would need some time to get to know the unit and service users. Account has been taken of this within the report and requirements. Of some concern was the deteriorating condition of the building, which requires some work to bring it up to an acceptable standard. What the service does well: What has improved since the last inspection? Some improvements had been made in service user-related documentation, though further work is also needed. Some improvements had been made to risk assessments, and in how the unit meets the health-care needs of service users. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 6 A new permanent manager has now been appointed for the unit which is an opportunity to take the unit forward, consolidate a permanent staff team and develop their skills and knowledge of the service users. The manager expressed ideas for developments in a number of areas. There was evidence of improvements in staff recruitment, which will hopefully begin to enlarge the core of permanent staff over the next few months. 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. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,5 The unit provides a statement of purpose and service user guide, in text and symbol/picture format. The needs and aspirations of service users have been assessed previously, but it was not possible to examine the current system as the group has been together a long time with no new admissions. Each service user has a statement of terms and conditions signed by their representative and a previous unit manager. EVIDENCE: There is a statement of purpose in place for the home. The previous acting manager produced a version of this using symbols and pictures to try to make it more accessible to service users. The new manager plans to review this document to try to ensure that it meets the needs of service users. There have been no recent admissions to this unit. The group have been together a number of years and moved here together from another, closing unit. It was therefore not possible to judge the current assessment process. Each service user has a standard statement of terms and conditions on file, and those examined, had been signed by their representative, and a previous unit manager. The document is not in a user-friendly format, and it was felt that none of the service users would be able to sign meaningfully. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,9 Service users are supported to make some choices and decisions in their daily lives, but there remains room for improvement in this area, particularly in terms of trying to develop the communication skills of service users to enable them to indicate their choices. Service users are supported to take risks within the context of a risk assessment system, but these need to be more readily accessible to staff. The fire risk assessment required reviewing. EVIDENCE: Care staff were observed giving choices to service users in some circumstances, but the manager acknowledged that this was an area she wished to focus on once the staff team had been consolidated. As yet the unit makes little use of Makaton or PECS (Picture Exchange Communication System) or other aids to communication. The manager wanted to explore these once she had developed her knowledge of the service users. It may be beneficial to involve the in-house behavioural therapist in further developing the communication skills of the service users. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 10 A range of individual risk assessments was in place and held within a collective file for ease of access. However, these were not clearly ordered and would benefit from separation by service user, within the file, for clarity. Some would also benefit from reviewing. There was a unit fire risk assessment but it was dated 2003. This should be reviewed and updated if necessary. The manager had identified a staff member to take a lead on fire safety in the unit, to whom she planned to delegate this. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Service users take part in activities on and off-site, but there is room for further development in this area of care, within a risk assessment context. Though they are part of the local community, service user involvement in it is limited mainly to use of the local shop and walks in the area. Service users were reported to have regular contact with family, but it is recommended that this be recorded within their files. EVIDENCE: Service users take part in a range of activities on and off-site, including walks, shopping trips, drives in the unit vehicle, but the new manager felt there was room for improvement in this area. One limiting factor could be the availability of a driver for the unit car, but there is also a need to have a higher proportion of permanent staff and to identify new opportunities within the community. The location of the unit, and lack of local facilities means that transport is usually needed to access activities in Newbury or Reading. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 12 The possibility of swimming had been identified in the care plan for one service user and this should be explored for her and others, within the context of appropriate risk assessments. None of the current service users is reported to pursue worship, though the manager should check that this is an accurate position. All of the current service users reportedly have regular contact with family and some receive visits. However, there was no specific record kept of contact with family, which made it impossible to verify this. It is recommended that a record sheet be established in individual files to record contact with and visits to/from family, to include keyworker contact. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20 There have been improvements in how the unit meets the health needs of service users. However, individual records of accidents to service users should be made in their files as well as maintaining the collective record for monitoring purposes. None of the current service users is able to manage their own medication. The unit has an appropriate system in place to manage this on their behalf. EVIDENCE: Individual health care plans were in place for each service user, and entries indicated that appropriate healthcare checks were now taking place, following a previous requirement for this to be monitored. Accident records also appeared to have improved though there is a need for records of accidents to be copied to individual service user files as well as being held centrally for monitoring purposes. None of the current service users is able to manage their own medication. The unit has an appropriate policy and procedure for managing this on their behalf. Responsibility for medication administration for each shift is identified within shift plans. Examination of medication records indicated they were appropriate, with the quantities of medication coming in now being recorded, following a 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 14 previous inspection requirement. There were no gaps in recent administration records. A returns log was also in place. The manager and one permanent staff are currently medication trained, together with three of the long-term agency staff. Once new permanent staff are recruited they will receive external certificated medication training, from the pharmacist, once they have completed their induction and foundation training. This is good practice. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Given the needs of service users complaints are most likely to be made in an advocacy capacity by staff or others. A more service user-friendly version of the procedure needs to be developed, which could be explained to them. There is also a need for a confidential background file to contain details of any investigations and relevant correspondence. EVIDENCE: There was a collective complaints log in place, which indicated no new complaints since the previous inspection. Given the needs of service users, it is likely that any complaints would come from representatives or keyworkers, acting in an advocacy role on behalf of a service user or from outside parties. There is a written policy and procedure in place, though the attempts to produce a service user-friendly version, by the previous manager, were very basic. The new manager undertook to look again at this to see if it could be developed further. A confidential background file should be established to contain the details of any complaints investigations together with copies of relevant statements, correspondence etc. The manager agreed to set this up. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25 Service user’s bedrooms were pleasant, homely and individualised to reflect their individuality. However, the condition of much the rest of the unit was poor and in need of redecoration to bring it up to an acceptable standard. The shabby hand-written notes to staff, posted about the unit, should be removed as they do not reflect well on the service, and staff should be reminded not to write on the walls. The garden needs to be revamped to make it an attractive space and the area of subsided patio must be repaired urgently. EVIDENCE: The communal areas of the building require some work to bring them up to an acceptable standard. In the lounge, areas of previous plaster damage and filler, remain un-painted and there is still no curtain rail across the patio doors. The conservatory remains untidy and under-utilised, which is a shame, as it provides an alternative communal space for service users. The blinds here are either missing or in shabby condition and are unsuitable for this setting. They should be replaced with a more suitable window covering. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 17 The dining area remains a cramped and not very homely area of the Kitchen, and requires redecoration of the walls. Throughout the unit there were numerous untidy hand-written notes stuck about the walls, (not by the current manager), instructing staff on aspects of what should be, basic care practice. For the most part, any instructional notices to staff should be reserved for the office. If they are absolutely necessary about the house, then they should at least be typed and laminated to improve their appearance, and perhaps provided discretely in a booklet or folder. The new manager agreed and planned to address this issue. There were also similar instructions actually written in biro directly on the shower room wall, which is totally unacceptable and does not inspire confidence in the care provided. Someone had also written telephone numbers on the wall above the upstairs phone. These areas should be repainted. Bedrooms were attractively decorated and individualised to reflect the interests and personality of their occupant. Bathing facilities remained satisfactory for the current needs of service users, but consideration should be given to their changing needs as this is an aging group, and additional adaptations are likely to be needed in the future to meet their needs. The garden is a good size, but appeared rather unkempt. The lawn was in need of mowing and some more creative planting was needed. The paving on the patio was in need of re-pointing and in one area, had subsided to present a health and safety hazard. This must be addressed as a matter of urgency. The new manager was hoping to be able to provide some sensory planting in due course and wanted to increase the involvement of service users in maintaining the garden. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34,35 Serviced users are now better protected by the improvements in recruitment records since the previous inspection, but the manager needs to confirm they fully meet requirements once the current applications are completed. The needs of service users will be better met once staff have their training needs more fully met. Their individual needs are now being identified. The unit will need to make progress on NVQ registration once the permanent staff have completed their induction and foundation training. EVIDENCE: Staff recruitment records were more comprehensive than previously, but the manager was due to meet with personnel to ensure that these fully meet the requirements. The requirements were clarified during the inspection. The manager should confirm to the inspector, that current unit recruitment records meet the requirements, once the current batch of applications are completed. The unit remains in need of a number of permanent staff, (5.5 vacant posts), though the continuity and consistency has been maximised through the use of a number of agency staff on a full-time basis. Leaflets and cards have been distributed locally to advertise for staff as well as local adverts and job fairs. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 19 The unit’s new manager, (two weeks in post), was aware that additional permanent staff were due to commence work over the next two months, once recruitment checks were completed, and had also referred some previously uncompleted applications to personnel for processing. The manager had already met with the Milbury training mananger, and a spreadsheet of the current training position had been established as a precursor to devising individual training plans for staff. The manager has NVQ level 4 and the Registered Manager’s Award, one staff member is due to commence on NVQ once their foundation training is completed, and other staff will need to be registered once they complete their induction and LDAF foundation training. The unit lags behind Government requirements on the proportion of staff with NVQ, but should consolidate this once additional permanent staff are recruited. The training spreadsheet identified a range of training needed by staff, including NVCI, (Non-violent crisis intervention), manual handling, first aid, risk assessment. Equal opportunities, adult protection, medication administration and fire safety. Some of these shortfalls had already been addressed through booking staff on relevant courses, and progress on this will be reviewed at the next inspection, but the manager should forward a schedule of the training booked for staff for the next six months, to the inspector. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39,42 It is unclear whether the views of service users and others have been obtained As part of a quality assurance strategy for the unit. This will need to be addressed and a copy of the summary report copied to the inspector, together with a copy of the annual development plan. The health, safety and welfare of service users is protected for the most part, though a number of shortfalls were identified. These must be addressed promptly. EVIDENCE: The new manager is due to meet with her line manager to discuss the issue of quality assurance, since no copy of the review of this was produced in response to the previous inspection requirement. The process should include obtaining the views of service users, families, funding agencies and other parties with an interest, and should generate a summary report, which is copied to the inspector and made available to relatives etc. 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 21 The quality assurance results should feed into the annual review of the care provided, together with inspection feedback, and any issues from complaints or Regulation 26 monitoring reports. This review should then generate the unit’s annual development plan for the next year. This cycle remains to be fully established in this unit, though the previous acting manager had produced an annual development plan, which had not been copied to the inspector. The new manager should review and update this document in consultation with her line manager, and copy it to the inspector. The majority of safety related service certification was available in the unit to indicate these issues were addressed. However, a copy of the most recent fire extinguisher service certificate should be obtained for the unit record and copied to the inspector. The frequency and appropriateness of previous fire alarm testing was unclear, but the new manager was clear about the requirement for weekly testing of call points in rotation, and was going to instigate this system. The unit’s fire risk assessment was dated 2003, and should be reviewed and updated. (Requirement made under standard 9, above). The new manager had also identified shortfalls in fire safety induction for staff, which she planned to address, as well as the need for additional staff to be trained on medication administration, first aid, moving and handling, food hygiene and NVCI. (Requirement already made at standard 35, above). There was no evidence that the deficiencies identified in the previous legionella survey of the building had been addressed. These works must be carried out and the certification should be filed in the unit. The identified area of subsided patio presents a health and safety hazard and must also be addressed. (Requirement already made at standard 24, above). 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x 3 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 x x x x x Standard No 11 12 13 14 15 16 17 x 3 2 2 2 x x Standard No 31 32 33 34 35 36 Score x x x 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 30 BROAD LANE Score x 2 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 9 9 13/14 Regulation 13 23 16 Requirement Risk assessments should be made more readily accessible to staff within the collective file. The unit fire risk assessment must be reviewed and updated. The opportunities for involvement in activities both in the unit, and within the community, should be increased. Individual records of accidents to service users must be made on their files in addition to the collective record for monitoring. This requirement remains outstanding from last inspection. Develop a more user-friendly version of complaints procedure. This requirement remains outstanding from last inspection. Identified communal areas must be redecorated to bring them up to an acceptable standard. Appropriate window dressings must be provided in the areas identified. The subsided area of patio must be repaired as a matter of urgency as it presents a hazard to staff and service users. H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Timescale for action 27/9/05 27/9/05 27/10/05 4. 19 17 27/8/05 5. 22 22 27/10/05 6. 7. 8. 24 24 24 23 23 23 27/10/05 27/10/05 27/8/05 30 BROAD LANE Version 1.40 Page 24 9. 34 19 10. 11. 35 39 18 24 The manager should confirm that 27/10/05 unit recruitment records meet requirements once the current applications are completed. Provide details of the training 27/9/05 booked for staff over the next six months, to the inspector. Copies of the summary of the 27/9/05 quality assurance survey and the annual development plan should be provided to the inspector. These requirements remain outstanding from last inspection. A copy of the certification for the fire exstinguisher servicing should be obtained for the unit and provided to the inspector. Address the identified remedial works within the legionella survey report. This requirement remains outsnding from last inspection. 12. 42 23 27/8/05 13. 42 13 27/9/05 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 7 Good Practice Recommendations Further improvement should be sought in the level of choice exercised by service users in their daily life, perhaps through work to improve their individual communication skills. Consider the establishment of a record of family contact sheet, within service users individual files. Establish a confidential background file to contain details of complaints investigations and associated papers. The hand written instructional notes to staff, on the walls about the unit, should be removed, and staff should be reminded not to write on the walls. The lawn should be mowed on a regular basis to make the garden attractive and accessible to service users. H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 25 2. 3. 4. 5. 15 22 24 24 30 BROAD LANE Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Reading RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 30 BROAD LANE H52-H01 11147 30 Broad Lane V235205 250705 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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