Inspection on 28/11/06 for 329 Fakenham Road

This inspection was carried out on 28th 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

329 Fakenham Road 21/10/08

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 329 Fakenham Road Taverham Norwich NR8 6LG Lead Inspector Mrs Lella Andrews Unannounced Inspection 28th November 2006 02:45 329 Fakenham Road DS0000067492.V322088.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 329 Fakenham Road DS0000067492.V322088.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. 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 329 Fakenham Road Address Taverham Norwich NR8 6LG 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) 01603 754915 New Boundaries Community Services Limited Manager application ongoing Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection This is the first inspection for the service Brief Description of the Service: 329 Fakenham Road is a three bedroom bungalow situated in a residential area on a main road into Norwich. The service is owned and managed by New Boundaries Services Ltd which also own several other care homes around the Norwich area. The service provides care and accommodation for up to three adults with a learning disability who also have challenging behaviours. 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first Inspection for the Home which was registered in June 2006. There are currently two clients living at the Home with a third due to move in shortly. The Manager, Bob Jenner, is currently going through the process of becoming registered with CSCI. This report contains information gathered about the Home since it was registered and includes the visit to the Home which was carried out on 28th November 2006 between 2.45pm and 7.15pm. The Manager had 24 hours notice of this visit as previous attempts to carry out an unannounced visit had been unsuccessful due to all clients and staff being out. Two completed comment cards were received from relatives and one from a client who had been assisted by a relative. An additional comment was made by a relative about how helpful the staff are and the fact that “…they go out of their way to ensure….well being.” Overall, the Home is providing a good service to the clients and is well managed. The fees from the Home are negotiated on an individual basis and currently range from £1,300 to £2,000. What the service does well: The Home is well managed by an enthusiastic Manager who ensures that the views of the clients and staff are taken into consideration. The bungalow provides a very high standard of accommodation, including ensuite bedrooms. The staff clear about their roles and are positive about their work with the clients. The staff receive good induction, training and supervision so that that they are able to carry out their roles effectively. Relatives are made to feel welcome and are satisfied with the care provided. The client who spoke to the Inspector said that they really like living at the Home. 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. 329 Fakenham Road DS0000067492.V322088.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 329 Fakenham Road DS0000067492.V322088.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 good This judgement has been made using available evidence including a visit to this service. An effective assessment process is carried out prior to clients moving into the Home. EVIDENCE: The first client to move to the Home moved from another Home owned by the organisation and so the manager and some staff knew the client well. The client told the Inspector that they had visited the Home on several occasions and had been able to have first choice of the bedrooms. The Manager and staff confirmed that the assessment process for the clients who were not previously known to the organisation has been very thorough and included gathering information from a range of sources, including meeting the client. The clients are encouraged to visit the Home to meet the other clients and staff prior to moving in. 329 Fakenham Road DS0000067492.V322088.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 good This judgement has been made using available evidence including a visit to this service. The needs of the clients are detailed within the care plans, which also include detailed risk assessments. Staff have a good understanding of the content of the care plans. Appropriate records are kept of the clients financial affairs. EVIDENCE: One of the care plans was seen. The Manager said that the format of the care plans is currently being reviewed across the organisation and that the new format will be implemented once staff have completed Person Centred Planning. There were some areas of the care plan which would benefit from 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 10 being updated more quickly than this and a recommendation is made about this. The client gave permission for the care plan to be seen and went to fetch it for the Inspector. He said that he knew what was in it and is involved when the staff update it. The care plans are detailed and contain evidence of assessments having been carried out prior to a service being offered to the client. There is evidence of detailed risk assessments being carried out for a range of issues relating to the individual client. However, it was noted that there was no risk assessment for one of the clients who assists the maintenance staff and a requirement is made with regard to this. The staff respect the clients right to make their own decisions and understand the importance of providing information to the clients so that they are able to make informed choices. The Manager and staff also understand the issues relating to balancing the rights of the clients to make their own decisions and the responsibility of the staff to ensure that the clients are safe and receive good care. The Manager explained the system for looking after the clients money. Records were seen which show that appropriate records of income received and expenditure are kept with receipts as proof. The cash held was checked against one of the records and found to be correct. It is recommended that a written record is kept of when the clients financial records are checked by senior managers/proprietor. 329 Fakenham Road DS0000067492.V322088.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 good This judgement has been made using available evidence including a visit to this service. The clients are supported to take part in work and leisure activities of their choosing and at a pace that suits them. Clients enjoy their meals and are encouraged to take part in all aspects of meal planning and preparation. Relatives are made to feel welcome and are kept informed of issues affecting their relative. 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 12 EVIDENCE: One of the clients has lived at the Home for approximately five months and has been able to continue with the programme of activities that he was involved with prior to moving from another Home within the organisation. The client spends a lot of time assisting the maintenance staff and said that he really enjoys doing this. A written risk assessment needs to be carried out for this (see previous section of report). The other client has only recently moved to the Home and is only just getting to know the staff and the local area. The client was supported to use the local shops during the time that the Inspector was at the Home. The Manager and staff are aware of the need to support clients to become a part of the local community at a pace that suits them as individuals. The care plans contain information about the leisure and work needs and preferences of the clients but the Manager and staff are aware that these may change as the clients feel more settled and are supported to try different activities. The Home has only recently had the use of a vehicle and this will make it a lot easier for clients to be supported to access the wider community, particularly when there are three clients living at the Home. One of the members of staff has been using their own car to provide transport. It is recommended that the Home has a clear policy about staff using their own cars and also for clients visiting staff at home. The two comment cards received from relatives both state that they are made to feel welcome when they visit the Home and that they are kept informed of issues affecting their relative. One of the relatives had written additional comments about how helpful the staff are. The clients comment card states that they are able to have visitors. One of the clients was supported to telephone their relatives during the visit. The clients are able to have a key to their bedroom if they wish to. Staff were seen to knock and wait for an answer rather than just walking into clients bedrooms. There was lots of communication between clients and staff during the visit. The clients were encouraged to be as much a part of the inspection as they wished to be. The clients comment card states that they are involved in food shopping and that they “sometimes” choose what to eat. However, the client then told the Inspector that they are always asked what they want for meals and can have an alternative to what is on the menu. Staff are encouraged to eat their meals with the clients. The clients are involved in the planning of menus, food 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 13 shopping and the cooking of meals if they wish to be. The staff are aware of the dietary needs of the individuals. Clients are also encouraged to take part in household tasks such as washing up and keeping their own rooms clean. The Manager and staff are very aware that the amount of involvement in these type of tasks varies between individuals and encourage clients in a calm and relaxed way. 329 Fakenham Road DS0000067492.V322088.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 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Support is provided to the clients in a way which respects their privacy and dignity. The personal and healthcare needs of the clients are met. Medication is managed effectively but there is a need for the Home to have an accurate medication procedure. EVIDENCE: Staff who spoke to the Inspector are very aware of the need to respect the privacy of the clients. Staff did not enter clients bedrooms unless invited to do so. The clients comment card states that they are able to keep their things private. 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 15 The clients who live at the Home are both male and the majority of the staff team are also male and so the clients are able to be supported by staff of the same gender if they wish to be. The clients currently living at the Home require little assistance with personal care. The care plans include information about the clients physical and emotional health needs with care plans providing guidance to staff about how to meet these needs. The care plans also contain evidence that health/social care professionals are involved in the clients care and that advice given is included in the care plans. The clients comment card states that the client is able to see their doctor and dentist. The medication system in use in the Home was looked at. Medication is stored appropriately and the necessary records of receipt of, administration of and the return of medication. An ongoing audit of medication is kept which is good practice. Staff do not administer medication until they have received training and are considered to be competent to do so. The medication procedure is not accurate as it has been copied from that used at another Home within the organisation. It is required that the Home has an accurate medication procedure. 329 Fakenham Road DS0000067492.V322088.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 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home has systems in place to enable the clients and relatives to raise any concerns/complaints. The staff receive training with regard to Safeguarding Adults but there is a need to update the procedure to ensure that it provides accurate guidance. EVIDENCE: The relatives comment cards both state that they are aware of the complaints procedure and the clients comment card states that they know who to talk to if they are unhappy about something. The Manager ensures that he spends time with both clients individually so that they are able to bring up any issues with him. One of the clients asked to talk to him during the Inspection and he ensured that this took place straight away. The staff who spoke to the Inspector are clear that the views of the clients are important and that they would take any concerns raised seriously. The Commission has not received any complaints about the service and the Manager confirmed that he has not received any. 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 17 The Home has a Safeguarding Adults (previously known as Protection of Vulnerable Adults) procedure but there is a need for this to be reviewed and updated to ensure that it provides clear guidance to staff about what to do if an allegation of abuse is made. A requirement is made about this. The staff have a good understanding of the rights of the clients and have received training with regard to Safeguarding Adults. They are confident that the Manager would deal appropriately with any concerns or allegations. The Manager has a good understanding of the action that would need to be taken following an allegation of abuse. 329 Fakenham Road DS0000067492.V322088.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 and 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The Home provides a high standard of accommodation which meets the clients needs. EVIDENCE: The accommodation has been decorated and furnished to a high standard. The lounge/diner is homely and comfortable with patio doors leading to a garden which the clients are encouraged to help look after if they wish to. There are three single en-suite bedrooms and the clients have been encouraged to personalise these as they choose. There is also a staff sleep in room/office which has storage for confidential information. 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 19 The kitchen and bathroom are both fairly small but are sufficient for the number of clients and staff at the Home. The washing machine is located in the kitchen which is satisfactory as the level of laundry is that of an ordinary household. There are gloves, aprons and hand washing liquid available in the kitchen and bathroom. The Home was very clean with no unpleasant smells on the day of the visit. 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The staff team are clear about their roles and are enthusiastic about supporting the clients. Appropriate recruitment procedures are followed. Staff receive training and supervision which enables them to carry out their roles effectively. EVIDENCE: The staffing structure for the Home is that there is a Manager, Team Leader and Support Workers. The Manager is also responsible for another Home within the organisation with the addition of a third shortly. Currently the Manager spends a lot of time in this Home but this will reduce as the third Home that he is responsible for opens. The Team Leader will then take on more of the day to day responsibility for this Home. 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 21 The Inspector spoke to existing staff and to some new members of staff who are currently undergoing their induction. All staff are clear about their role and are enthusiastic about working in a new service and supporting the clients. There has been some use of agency staff at the Home but it is expected that this will stop once the new members of staff have completed their induction. The Manager said that once the third client moves into the Home there will always be at least two staff on duty. The organisation has appointed a Training Manager and consequently induction is planned and provided in a timely manner, adhering to the Common Induction Standards as advised by Skills for Care. Currently more than 50 of the staff team have achieved NVQ Level 2 and the Manager is aware of the need to ensure that this is maintained as new staff join the team. The staff who spoke to the Inspector have a good understanding of the needs of the clients and of the content of the care plans. They, including new staff, are also clear about the aims of the Home and the fact that the needs of the clients are the basis for the routines of the Home. The organisation follows appropriate recruitment procedures and the Manager is involved with recruiting additional staff for the team. Criminal Record Bureau disclosures are kept at the Head Office for the organisation and the Inspector carried out a visit to see a selection of these in October 2006. The staff said that they receive very good support from the Manager and Team Leader. They said that they are available for informal support as well as more formal support with regard to meeting the needs of the clients. It is recommended that records are kept of the supervision/support sessions provided to the staff. 329 Fakenham Road DS0000067492.V322088.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, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager has an open and positive approach to management which values the views of clients and staff. The Home has systems in place to regularly monitor the quality of the service provided and the Manager is aware of the need to provide an annual quality assurance report. The health and safety needs of the clients and staff are given a high priority but there is a need for additional records to provide evidence of this. 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Manager has previously worked within the organisation as a support worker and a team leader. He was promoted to manager six months ago and has been managing another Home within the organisation as well as setting up this Home. He is also currently involved with setting up another Home which he will manage when it opens. The Manager has completed all mandatory training and has undertaken management training with the organisation. He has started to complete the Registered Managers Award. He is aware of the areas in which he needs to increase his knowledge/experience and has plans in place to address this. The Manager receives support from the Operations Manager and, more informally, from the other managers within the organisation who meet regularly. He also takes part in the on-call system for the organisation. The client who spoke to the Inspector said that the Manager is “good at his job” and that “you can talk to him”. The staff spoke highly of the Manager, saying that he provides very good support to them and also acts as a good, positive role model. The Manager has an open and positive approach to management with systems in place to ensure that the views of the clients and staff are taken into account when making any decisions. This forms the basis of the Homes quality assurance process. There are systems in place for recording some of this consultation, such as care plan reviews, questionnaires to relatives, team meetings, clients meetings. The Manager is aware of the need to ensure that all of these systems are brought together in an annual quality assurance plan. A requirement is made about this. It is also required that visits are carried out as per Regulation 26 and that a copy is sent to the Commission as these are not taking place on a monthly basis. The organisation took advice from the Fire Officer prior to opening the Home. There are linked smoke detectors and emergency lights in the bungalow as well as a fire blanket and extinguisher in the kitchen. The Team Leader is responsible for ensuring that regular checks are carried out for the fire safety equipment. It is required that a fire risk assessment is carried out and a record kept of this. During the most recent monthly visit carried out at the Home (Regulation 26) it was noted that some work needs to be carried out to the steps into the garden to ensure that they are safe for all clients. It is required that a written risk assessment is available for the Home, including the gardens. 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 24 The Manager has systems in place for recording other health and safety issues, such as a record of accidents, record of fridge and freezer temperatures. The Manager said that the hot water temperature is regulated to reduce the risks to the clients. The organisation owns several homes around the Norwich area. The organisation does not have computers within the Homes and therefore, no means of gaining the benefits of electronic communication. This means that any documents/records that need to be typed eg. Care plans, review notes, etc have to be sent to the head office for typing and then returned. This may take several days, if not weeks, and in the meantime the information is not available within the Home. It would also be beneficial for the Responsible Individual and the managers within the organisation to be able to communicate by email. 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 25 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 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 4 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 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 2 X 3 3 2 X X 2 X 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 26 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 YA9 Regulation 13 (4) Requirement It is required that a risk assessment is carried out for the client who assists the maintenance staff It is required that the medication procedure is accurate for the Home It is required that the Safeguarding Adults procedure is accurate It is required that monthly visits are carried out to the Home by the organisation and that a report is sent to the Commission It is required that an annual quality assurance report is produced and that a copy is sent to the Commission It is required that a fire risk assessment is carried out It is required that a health and safety risk assessment is carried out for the Home, including the gardens Timescale for action 31/01/07 2 3 4 YA20 YA23 YA39 13 (2) 13 (6) 24 31/01/07 31/01/07 31/01/07 5 YA39 24 30/11/07 6 7 YA42 YA42 13 (4) 13 (4) 31/01/07 31/01/07 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 27 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 4 Refer to Standard YA6 YA7 YA13 YA36 Good Practice Recommendations It is recommended that the care plan for one of the clients is updated It is recommended that a written record is kept of audits of the clients financial records It is recommended that the policies regarding the use of staff cars and clients visiting staffs homes are clarified and discussed with staff It is recommended that records are kept of all supervision/support sessions 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 329 Fakenham Road DS0000067492.V322088.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!