Inspection on 13/12/05 for 39 High Barn Close

This inspection was carried out on 13th December 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

39 High Barn Close 02/04/07

39 High Barn Close 12/07/05

39 High Barn Close 30/11/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 39 High Barn Close 39 High Barn Close Rochdale Lancs OL11 3PW Lead Inspector Jenny Andrew Unannounced Inspection 13th December 2005 10:15 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 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 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 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. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 39 High Barn Close Address 39 High Barn Close Rochdale Lancs OL11 3PW 01706 648535 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) Pendleton Care Ltd Mr Anthony Lee Walsh Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 3 service users to include: up to 3 service users in the category of LD (Learning disability) The service should employ a suitably qualified and experienced manager who is registered by the Commission for Social Care Inspection. 12th July 2005 Date of last inspection Brief Description of the Service: High Barn Close is a large semi-detached house set in a cul-de-sac in its own grounds. It provides long-term, 24 hour care for 3 younger adults with learning disabilities. The organisation specialises in the care of young adults with autism. The home provides roomy communal accommodation in a lounge, separate dining room and kitchen. All bedrooms are single and one is situated on the ground floor in order that service users with physical disabilities may also be accommodated. A post office and corner shop are in walking distance and Rochdale town centre, supermarket and other amenities are within half a mile radius. Buses to and from Rochdale and other local towns pass close by. A car park is not provided although on-street parking is available. Access to the main door is via 4 steps. A lift to the first floor accommodation is not provided. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over five and a quarter hours. The Inspector looked around parts of the building, checked the care plans and some of the other records. As two service users had limited speech, the Inspector watched how they made their needs known to the staff. In order to obtain information about the home, the manager, 3 service users, 2 support workers and the team co-ordinator were spoken with. What the service does well: What has improved since the last inspection? Most of the building requirements, made at the last inspection, have been put right, although there are some areas in the home which still need to be redecorated. The manager was part way through having the care plan of one of the service users, translated into his own language so that the family could easily understand it. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 Page 6 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. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 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 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: The Core standard 2 was assessed at the last inspection. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 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 the following standard(s): 6&7 There was a clear consistent care planning system in place, incorporating monitoring and reviewing arrangements, which provided staff with the detailed information they needed in order to meet the service users needs. Staff supported and enabled service users to take control of their own lives, as far as possible, within the constraints of risk assessments. EVIDENCE: The care plans of all 3 service users were seen. The plans were comprehensive covering: biography information, preferences about daily routines, communication abilities, leisure/social activities, independence, behavioural profile and identified any potential adult protection safeguards. Given the specialist nature of the care provided, detailed behavioural and management strategies for challenging behaviour were also in place. All documentation had been reviewed and updated on a regular basis. All parties were fully involved in the care planning process at review meetings but they had not signed to say this was the case. The manager will make sure signatures are obtained at future reviews. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 Page 10 In addition to the care plan, each service user had a Person Centred Plan (PCP), illustrated with photographs, which were meaningful to the individuals. The staff had continued the good practice of formulating both long and shortterm aims/goals for each person, which were reviewed during the key-worker meetings and at 3, 6 or 12 monthly reviews. Areas addressed were practical and vocational skills, personal care, community and leisure, daily living skills, communication, literacy and numeracy. Staff interviewed demonstrated they were attentive to changes in the needs and behaviour of the individual service users. Whilst there had been some turnover on the staff team, there was evidence of good team working which was vital in ensuring that each service user was supported with their chosen individual daily routines. Any changes were monitored, reviewed and shared with the whole team to make sure each person was supported in a consistent way. The high level of staff commitment towards motivating service users, identified at previous inspections, has continued. The staff have a very good understanding of the service users support needs and this was evident from the positive relationships, which have been formed between the staff and service users. Communication with the service users was difficult and it was hard to identify whether they felt their needs were being met. However, one person gave the “thumbs up” sign in relation to liking the staff and the support he received. The service users’ right to make decisions about their lives and every day routines is respected by the staff. Evidence of this was seen in the staff communication and handover books and in the daily diaries, which are kept for each of the three service users. Where service users had declined to get up, go to bed, bath/shower or have their hair cut clear recordings had been made. It was however, clear that staff balanced the service users rights to choose with what was detrimental to their well being i.e. missing meals, staying in bed all day etc. and in such instances, they worked hard at motivating them to achieve their aims/goals which had been agreed with them. Key-worker weekly meetings were held on a Sunday, when the service users would plan out what they would be doing the following week i.e. outings, personal care tasks, household chores etc. Service user meetings were also occasionally held but it was felt that one to one time was the best way of empowering service users in the decision making process. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 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 the following standard(s): 12, 15 & 17 The range of opportunities available for service users to pursue leisure and intellectual activities reflected the diversity of the service users and their social, intellectual and physical capabilities. The home valued the role that relatives and friends could continue to play in the lives of the service users and their participation was encouraged. The dietary needs of service users are well catered for with a balanced and varied selection of food, which meets individual tastes and choices. EVIDENCE: The staff are constantly trying to give the service users opportunities to learn new life skills in order to make sure they have fulfilling and meaningful lifestyles. Clearly, there are limitations on what education/employment opportunities there are as each of the service users has very differing abilities. Two of the service users attend a development centre twice a week in an afternoon where they work to a planned programme, which includes numeracy and literacy skills. Staff were continuing to identify possible new activities for 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 Page 12 the other service user to participate in but were mindful these would have to be introduced slowly. Staff encouraged each individual to have structure to their day within each persons’ preferred daily routines and, as previously stated, each person was supported to achieve their set daily living aims/goals. In addition, a variety of community-based activities were being offered. The home had its own transport although one service user did occasionally use public transport whilst another would, if necessary, utilise taxis. Rotas were written to accommodate each person’s planned activities but on occasions, due to staff absences, they would be changed. On the day of the inspection, a member of staff who normally worked nights, had been asked to come on duty early so that he could take a service user to the development centre as there was no other driver on duty. From evidence seen during the inspection, it was clear that staff supported service users to maintain family links. They also kept a list of significant birthdays so that each individual could be supported to send cards and buy presents, as they chose. Staff were presently in the process of assisting service users to purchase Christmas presents and write cards to their families/friends. The staff team were good at keeping families advised of any changes in the support needs of individuals and also regularly asked families for feedback on what they thought of the service. Families were always invited to review meetings so they could be fully involved in any decision-making processes. One service user enjoyed attending the Gateway Club where he had made some friends. Service users had opportunities to be involved in menu planning, laying and clearing away tables and one person sometimes assisted staff with making snacks. The staff spoken with said they were mindful that the service users should eat healthily and they tried to do this at the same time as being aware that there would be some foods, which would not be acceptable to the service users. All meals were recorded on menu sheets and these records showed that the staff were catering for individual tastes and choices. During the inspection, it was noted that flexibility of mealtimes was essential to fit in with each person’s chosen routines. Takeaways were clearly enjoyed and these are offered, on a weekly basis. Meals out were occasionally planned, but more informal settings were said to be enjoyed i.e. pub snacks or going to cafes. Where service users had specific nutritional needs, these were assessed and regularly reviewed. At the time of the inspection, a referral had been made for a dietician to become involved in assisting staff with the planning of menus for one of the service users and the advice of a Doctor had also been sought. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 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 the following standard(s): 19 The arrangements in place ensured that the residents’ physical and emotional health care needs were being met. EVIDENCE: Each person had a medical file, which recorded all visits and involvement with health care professionals. All medical appointments were noted in the diary and reinforced at shift handovers. Medical intervention was sought at an early stage, when any of the service users were identified as having any behavioural or physical problems. At the time of the inspection, a referral had been made for the involvement of a dietician and one person was seeing a behavioural psychotherapist. The District Nurse was also seen during the inspection and she was visiting weekly to check on one of the service users medical conditions. One person had attended a podiatry appointment on the day of the inspection. The key worker system was effective and meant that each of the service users was being supported by staff who knew them well. This also ensured that any changes in the patterns of behaviour of each person were quickly identified so that appropriate action could be taken to support and assist the person in working through their problems. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 Page 14 Detailed recordings were in place in each of the files, in relation to any physical intervention which staff had had to use and staff had received the appropriate training. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 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 the following standard(s): 23 Satisfactory policies/procedures were in place in relation to the protection of service users but not all staff had received relevant protection training. EVIDENCE: Appropriate policies and procedures in relation to the protection of vulnerable adults were in place and staff are not employed to work at the home before all appropriate checks have been undertaken. Physical intervention is used only as a last resort by trained staff and only then to protect the rights and best interests of the service user. The staff team favour trying to prevent a service user from reaching the point where physical intervention becomes necessary i.e. de-escalation. Concise recordings were seen where any physical intervention had been initiated. The manager is qualified to undertake staff training in this area and arranges regular courses for all staff employed by the company. Refresher trainer is also undertaken. From training records seen, it was evidenced that 10 staff had undertaken such training this year and another 5 were booked to attend on 19 December 2005. From checking care plans, good practice was noted in relation to risk assessments being in place for the vulnerability of service users. It was identified that other than 4 support staff, who had undertaken NVQ training, only I other person had received any protection of vulnerable adult training. This shortfall must be addressed. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 Page 16 Policies/procedures were in place with regard to the protection of service users, which encompassed service user finances, confidentiality, fire, emergencies and missing persons. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The standard of décor and furnishings within the home needed improving further in order to provide a more homely, attractive environment for the service users. The home was clean and good infection control practices were in place. EVIDENCE: Standard 24 was fully assessed at the last inspection, but was re-visited on this occasion, due to the shortfalls in the furnishings and décor previously highlighted. Some improvements had been made in relation to safety e.g. the fire door in the kitchen had been repaired, the window restrictors in 1 bedroom had been replaced with those with a narrower opening, some re-plastering worked had been done and the gas hob had been changed to an electric one. The lounge carpet had also been cleaned. Although a requirement had been made in the last report for the settee to be repaired or replaced, this had not been actioned. The manager stated a settee had been ordered but they were awaiting delivery and a date had not been given. He further stated he had requested another new settee and a chair but 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 Page 18 that in order to lessen the changes for the service users, these would be introduced gradually. Several areas within the home were in need of re-decoration where the plasterwork had been done and also where service users had shredded the wallpaper. An environmental health inspection had taken place on 10 October 2005 when a recommendation had been made for the kitchen drawer to be repaired. Whilst this had been done, another drawer front was missing and this must be repaired and replaced. The home was seen to be clean and free from any offensive odours. A supply of disposable gloves and aprons was held in the office and all soiled linen was put into red bags, which went straight into the washer. Due to problems experienced with one of the service users, liquid soap was kept in the office and staff would take this with them when they needed to wash their hands. Dry alcohol based hand washing lotion was also utilised. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 & 36 Whilst the service users were supported by an effective staff team, continuity and stability has been eroded due to staff absences, which has had a negative impact on the service users. Regular supervision ensured that staff were managed to support good practice and professional development. EVIDENCE: Staffing levels are currently meeting the needs of the individual service users. This was evidenced from checking the communication book, care plans, staff meeting minutes and reviews as well as talking to staff and service users. From interviewing staff and checking staff training records, it was felt that the staff team were competent, efficient and committed to providing good care to the service users. The team reflected the gender composition of the service users with 4 male workers being employed. It was however, identified, that due to two staff being on long term sick and another support worker being moved to one of the organisation’s other houses, continuity of staff has not been maintained. Whilst it is acknowledged some absences cannot be controlled, the moving of staff between houses can, and, for the continued well being of the service users living at High Barn, such practice should be avoided. The move meant that agency workers had to be employed in order that the rota could be adequately covered. Whilst the same 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 Page 20 staff were utilised wherever possible, the change in staff to the service users resulted in heightened anxiety and fixated behaviours. Feedback from service users at review meetings indicated they had been distressed with the staff changes. Staff were unclear as to why the other house had not utilised agency workers as clearly both houses had suffered, rather than one, from employing staff whom the service users were unfamiliar with. Regular staff meetings were taking place with minutes being recorded and held on file. Whilst the recruitment standard was not fully inspected on this visit, whilst checking staff personnel files for evidence of Criminal Record Bureau checks and staff photographs which had been required at the last inspection, it was noted that for one new support worker, there was no application form or references held on file although they were said to be held at the head office. Duplicates must be obtained and held in-house. At the last inspection, it was identified that staff were not completing their induction and foundation training within the required timescale. On this inspection, the file for one of the more recently employed support workers was checked and his induction training record was incomplete. Staff spoken with all confirmed they received regular supervision and this was confirmed from supervision records seen. The manager and the team coordinator are responsible for supervising the team between them. Whilst annual appraisals are undertaken, only 2 of the staff had yet been part of this process for this year. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 The manager gives clear guidance and direction to staff to ensure the needs of the service users are met. The home regularly reviews aspects of its performance through a selfreviewing and consultation programme which includes seeking the views of service users, social workers and relatives. EVIDENCE: The manager has had considerable experience in a management capacity and has undertaken his NVQ level 4 in care, together with the management units of the Registered Managers Award. He is awaiting verification and will then send a copy of his training qualification to the CSCI. He works to his job description ensuring he keeps abreast of current practice by attending refresher training courses. Staff interviewed described his management style as “supportive”, “fair” and “efficient” and also said “he will always make time for me”, “is there if you 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 Page 22 have any problems” and “is flexible and willing to listen to what you have to say”. All staff interviewed confirmed they had been issued with a copy of the General Social Care Council “Code of Conduct” booklet and a note on their personnel file showed this was the case. The home had an effective quality assurance and monitoring system in place to measure their success in achieving the service’s aims and objectives. As previously stated, service user and key worker meetings were held regularly with the service users. In addition, 3, 6 and 12 monthly reviews were undertaken involving key workers, service users and family members. Care managers were also involved in the external reviews. Evidence was seen of how service users/relative comments/requests from review meetings were being actioned by the staff team i.e. samples of new bedroom flooring were being considered and a bedroom was to be re-decorated within an agreed timescale. 3 monthly summaries of service user’s progress were sent to appropriate persons i.e. family/advocates/care managers covering health, diet, personal care, communication and activities and feedback was actively sought. Family/advocates and service users were circulated with quality feedback questionnaires on a 3 monthly basis and these were held on files. Representatives of Pendleton Care were undertaking monthly audit visits to the home and reports were held in-house and also sent to the Commission for Social Care Inspection. Policies/procedures were regularly reviewed and updated in the light of any changes in the legislation. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 X X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 39 High Barn Close Score X 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X 4 X X X X DS0000062678.V272383.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? YES 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. 4. 5. 6. Standard YA24 YA23 YA24 YA24 YA34 YA34 Regulation 16 13 23 23 19 19 Requirement The settee must be repaired or replaced. (Previous timescale of 30.09.05 not met). Staff must received Protection of Vulnerable Adult training. The areas identified in the report must be re-decorated. (Previous timescale of 30.09.05 not met) The kitchen drawer must be repaired. A staff photograph must be on each persons personnel file. Application forms, references and evidence of CRB checks must be held in-house on staff personnel files. All staff must receive induction and foundation training within 6 months of employment. Timescale for action 31/01/06 31/03/06 31/01/06 31/01/06 31/01/06 31/01/06 7. YA35 18 31/03/06 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 Page 25 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. Refer to Standard YA33 YA36 Good Practice Recommendations The practice of moving staff from High Barn to Beech Hill should cease due to the negative effect this has on the service users. All staff should receive annual appraisals. 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 39 High Barn Close DS0000062678.V272383.R01.S.doc Version 5.0 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. 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!