Inspection on 06/11/06 for 47 Festing Grove

This inspection was carried out on 6th November 2006.

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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

47 Festing Grove 16/05/07

47 Festing Grove 07/11/05

47 Festing Grove 08/06/05

47 Festing Grove 18/01/05

47 Festing Grove 09/06/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 47 Festing Grove Southsea Hampshire PO4 9QB Lead Inspector Clare Hall Unannounced Inspection 6th November 2006 10:00 47 Festing Grove DS0000011687.V322244.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 47 Festing Grove DS0000011687.V322244.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. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 47 Festing Grove Address Southsea Hampshire PO4 9QB 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) 023 9283 2427 www.c-i-c.co.uk. Community Integrated Care Miss Michelle Callard Care Home 4 Category(ies) of Learning disability (4), Physical disability (1) registration, with number of places 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of one service user in the category PD referred to above may be accommodated at any one time. Date of last inspection Brief Description of the Service: 47 Festing Grove is situated in Southsea, in Portsmouth and is managed by Community Integrated Care (CIC). The home is close to local shops and a short walk away from the sea front of Southsea. Residents of the home have access to the homes car and therefore further a field facilities can be accessed. The home is a two storey house consisting of four single bedrooms of which two are on the ground floor and two on the first floor. The home has two bathrooms both are close to service user bedrooms. On the ground floor is a lounge, kitchen and open plan dining room. To the rear of the property is a small courtyard garden and the front of the property leads directly into the road. The fees are between £1000 and £1100 a week. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector undertook a visit to the premises and during the time spent there spoke with one service user, two care workers and the acting manager. Two service users chose not to state their opinion of the service and declined to fill in a questionnaire with the support of staff. One service user was happy for the inspector to be shown his room. The pre inspection information requested by the commission was not provided. The acting manager was unable to recall any request made for additional information pre inspection. Additional information considered was all the recorded contact with the home, including events, Regulation 37 notifications, Regulation 26 visit summaries and the information contained in the previous reports. Comment cards were provided to the service, pre visit, but no responses were received. Staffs were observed throughout the afternoon assisting and supporting clients and their practices were observed for good practice. Case tracking was undertaken as part of the evidence gathering process. What the service does well: The inspector was informed that the service provided is extremely good. One comment was, “ there is such encouragement to support the clients to get out into the community and with the amount of choice they are given. They virtually have the choice in respect of everything they do.” Further comments received were, “There have been a couple of problems with staff but overall they are great.” “The acting manager has been really supportive by explaining and showing me things and answering my questions.” 47 Festing Grove DS0000011687.V322244.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. 47 Festing Grove DS0000011687.V322244.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 47 Festing Grove DS0000011687.V322244.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): 1,2,3,4,5, Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The service has clearly been unsupportive to one service user during transition causing unnecessary distress. The lack of records and poor quality information further exacerbates this. EVIDENCE: The available information regarding the service is outdated and refers to the old manager. Staffing levels described have changed and so have the accommodated service users. The information is not in a suitable format and it is not freely available. One service user has been admitted since the last visit. It has been established that this service user had been undergoing transition since last November from another home. It was stated that he had met two staff from his new home and was going to move in with one member of staff from his current home. The move did not go ahead as planned for some five months. The staff member who was to accompany and support him left and the two staff he had been introduced to were away when he moved in. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 9 Correspondence with the commission identified that this service user was exhibiting some challenging behaviour since admission and was causing some considerable disruption in the home. It was reported he was very unsettled. No records could be found of how this service user had been assessed pre admission or supported during transition. The inspector could not establish what steps were taken to ensure he and his future housemates were consulted or how it was established they would be compatible. It was further established that the move occurred when it was considered to be financially viable rather than at the best time for the service user. A lack of consistent manager during this time further complicated this service users admission/transition. The current manager could not find the relevant pre assessment information to identify that the service user knew that the home they had chosen would meet their needs. Files did indicate terms and conditions have been provided. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,910 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Quality in this area is adequate. This judgement has been made using available evidence, including a visit to this home. Service users are clearly supported and offered choices. Regular care management reviews have not been maintained. Service users are not having the opportunity to communicate whether they feel their aspirations to live ordinary meaningful lives in their current placement are met by the provider. The evidence of service user consultation and decision-making could be developed further. Service user records need to clearly indicate a process of audit and review involving consultation. Records could be streamlined and easier to read. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 11 EVIDENCE: Plans have been formulated identifying the needs of service users. There is an extensive amount of information available. This could be bettering organised. The acting manager did state she has been archiving a lot of the service users information. The records indicate that key workers have undergone lifestyle-planning sessions with service users. Service users do have the opportunity during this time to identify what their needs are and indicate what support they feel they need. This opportunity could be developed so as to elicit the views of service users regarding their current accommodation, expectations and lifestyle. Care plans do not indicate they have been read and agreed with the service users, as the life style planning appears to be undertaken separately. The records could be streamlined so that all the information reflects the needs of individuals. Two records, which had been reviewed, indicated that service users were on certain medications, which they were not receiving. One service user had specific gender care requirements for supporting his hygiene needs. He also had certain staff/peer relationship difficulties. The actions to limit any risks could be expanded so to protect staff and peers. There are good daily records, which record outside and indoor activities undertaken, general mood, incidents, communication and sleep. Care plans clearly identify the needs of individuals but not their short and longterm goals, or the processes for promoting independence. Improvements are necessary for the recording of assessments, planning and evaluating the support given. It was very clear that staff were very aware of individual’s needs and preferences. Staff were observed being sensitive to the needs of individuals. The everyday processes for offering choices, seeking service users opinions and involving them in the development of the service needs to be reflected in reviews and audit processes. One concern identified was that two service users have alarms on their bedroom doors. A requirement was raised at the last visit twelve months ago regarding one bedroom door, which had an alarm fitted stating, “The home is required to implement a suitable procedure following consultation with the service users care managers regarding the use of an alarm on a service users bedroom door.” 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 12 On this occasion it was found that there are now two rooms with alarms fitted and the acting manager was unaware of this previous requirement, which has not been addressed. The inspector could not find any evidence to indicate that all service users are receiving regular care management reviews and one-service users is stated not to have a care manager. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 13 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): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities are given for service users’ education and integration into the community. Staff support service users leisure needs. EVIDENCE: It was observed that service users attend clubs, leisure activities and colleges for further education. Staff confirmed that there are excellent opportunities for service users to go out, supported by staff. One service user was going off to the cinema and later in the week was going to be accompanied by staff on a trip to Florida for his holidays, which he was very excited about. Also at the previous visit in November 2005 it was established that staff had requested a review with care managers regarding one service user who no 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 14 longer had a care manager. Staff stated they were waiting for a response. A requirement was made at that time. It was concluded that the acting manager was not aware of this issue and requirement, as she did not have access to the last report. This service user remains without a care manager. Service users have access to good kitchen facilities. Pictorial formatted menus were seen displayed and weight monitoring is undertaken. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff are sensitive to the personal preferences of individuals in respect of same gender care. Health needs are met through regular checks and staffs are trained to support the medicinal needs of individuals but healthcare assessments need some updating. EVIDENCE: The homes duty rota and daily staffing provision has needed to be adapted to meet the individual preferences and needs of individuals. There is a clear incompatibility between some service users, which requires constant supervision by staff. The four individuals living together have not been housed in relation to their individual preferences or compatibility as a group but it has been stated they are supported as much as possible. The number of Regulation 37 reports would indicate that there are frequent conflicts between clients in the home and this is managed by respecting personal spaces and allowing individuals the privacy of remaining in their room 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 16 as they prefer and by staff monitoring the signs of frustration and being sensitive to the triggers. One service user needs full assistance for personal care and will only consent to certain individuals supporting him. Only those staff he has established a rapport with undertake his personal care needs. Staffs were being very supportive and sensitive to his needs and they have adapted the duty cover to ensure his needs can be met. The home has also employed more male care staff to support and meet same gender care issues/needs. The home does accommodate service users with quite complex care needs. The organisation provides a good level of training in medication and written records indicated a level of audit is undertaken to ensure the medication administration records are completed in full. Service users files indicate NHS entitlements are maintained. The service users healthcare assessments are in need of review, as they have not been updated. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service needs to expand the process of monitoring the issues and concerns of service users. Reviews have not been regularly undertaken of risk assessments and strategies developed. There is no cycle of audit to ensure the service users feel safe are happy or have representation. EVIDENCE: It was established the complaints procedure is under review. There are plans to put this in a video format. It was identified that some service users are at risk of abuse. Strategies have been developed for one service user who makes frequent allegations of abuse. A strategy has been developed to ensure future allegations are given all the consideration under protection procedures whilst safeguarding the possibility of ignoring a genuine incident. This has not been included in any documented review. The processes for ensuring the risk is understood by all staff needs to be clearly documented and what actions are taken in respect of this .The actions should be identifiable in the service users care records so all staff including bank staff can be aware of any risk to themselves or the service user. This should be done within a risk assessment framework. The staff have not ensured that regular reviews are undertaken by care managers to ensure the best interests of service users are maintained and their concerns listened to. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 18 Processes for reviewing service users satisfaction and access to advocacy and representation is limited. Regular reviews have not been undertaken for 17 months. Nor are staff are not recording when people are on the premises. Staffs spoken to are aware of protection policy and have received training in dealing with challenging behaviours. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 19 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): 24,25,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and well equipped and meets the needs of the service users. EVIDENCE: The accommodation provided is clean and well maintained. The service users were observed using the laundry facilities independently and making good use other communal space. The home had been nicely decorated with a Halloween theme. Individual service users’ rooms were personalised and fully furnished with quality items. The kitchen is clean tidy and well equipped. Dining facilities are pleasant overlooking the paved patio area. The home has a large down stairs bathroom, which can accommodate persons with physical disabilities. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 20 The staff undertake the cleaning duties and they manage this to a high standard. The laundry does lack a hand towel dispenser. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 21 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): 32,33,34,35,36, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The majority of staff have expert knowledge about the individual care needs of the service users in their care. Those less familiar with service users are supported through training and supervision. The organisation provides a good level of training and development for staff. EVIDENCE: The acting manager stated the house no longer has an awake night worker employed but one sleep in night worker. This was said to be changed in respect of the service users not requiring help at night. The inspector was concerned that the service users bedroom doors were also alarmed to monitor service users movements at night in respect of their being no awake night staff. One recorded comment seen was a message to staff which stated “Can you get Mr x up on Saturday morning .I know its early but shifts have changed and there is no one to do Mr x. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 22 Staff stated that staffing numbers have improved since and all staff spoken with felt the numbers were appropriate to the needs of the service users accommodated. Documents indicated there is a good level of training, induction and supervision given to staff. Staff felt supported and are given training related to the specialist care needs they are expected to meet. Training is provided in lines with the skills for care council. Two staff recruitment records were audited. All necessary documents were in place and this would indicate there is a thorough recruitment process undertaken. Staffs were complimentary regarding the level of support given to them. Regular feedback regarding performance was seen on staff files and the organisation has a good process for the training development and supervision of its staff. It was also reported that they’re re some improvements being made to the induction for staff but the acting manager was having difficulty accessing these. The service ensures they provide familiar staff to support service users. They ensure they use the same regular bank staff. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 23 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): 37,38,39,40,41,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffs feel supported. The acting manager is doing a good job, short term, in ensuring staff are supported and trained. The service is at a stand still as there are no processes to adequately audit and review the service provision on a continuous cycle. Efforts could be made to ensure the service is driven by the needs of service users and the home is need of registering a permanent manager. Issues raised at inspection are not being addressed and the Regulation 26 summaries offer limited information. Service maintenance is ongoing but clarification regarding the homes fire risk assessment and portable appliance checks will be needed. 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 24 EVIDENCE: It was established that the registered manager left three months ago and was on extended leave for six months prior to that. There has been an acting manager in place these last three months but she states she has no plans to stay long term. The organisation has failed to appoint some one in the recent rounds of interviews and the position remains vacant. The processes in the home remain at a stand still and have not been developed further. There is no evidence that processes for auditing and driving the service provision forward has been undertaken. The acting manager does not have the historical knowledge of what the issues and concerns may be regarding the service or what the goals are in respect of further improving the provision. There has been a lack of quality audit and the standard of the current Regulation 26 information is poor. It does not reflect a cycle of quality audit. The acting manager is attempting to sort through the accumulated documentation, archive and update the files. As acting manager she has limited access to the organisations computer held information and this includes training and induction information. The previous registered manager was contacted by phone on a number of occasions when clarification was necessary by the staff during the visit. Service records did indicate service checks had been undertaken but there was some confusion regarding the portable appliance checks and whether they have been undertaken or not. In view of the changes in the Fire Regulations (October 2006) there is no evidence to indicate a review of the home fire risk assessment has been undertaken. Staffs are having regular fire training and equipment checks have been done. The risk assessments in relation to the building have been updated and reviewed. Despite the manager being in an acting position she has years of management experience in a similar environment. She has also known the majority of service users for a number of years and has established a good rapport with them all. Staff stated they felt supported by the acting manager. The acting manager also took time out of her day off to support the inspector. 47 Festing Grove DS0000011687.V322244.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 2 2 1 3 1 4 2 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 2 2 3 2 2 X 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 26 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. Standard YA7 Regulation 42 Requirement The home is required to implement a suitable procedure following consultation with the service users care managers regarding the use of an alarm on two service users bedroom doors. This has been raised previously and has not been addressed by the given date of 31/01/06 The provider must ensure that staff obtain reviews of care for service users living in the home. This has been raised previously and has not been addressed by the given date of 31/01/06 The registered person must ensure that the information regarding the service is updated and provided in a suitable format for the people it aims to provide a service for. The provider must ensure that service users are only admitted following a comprehensive needs DS0000011687.V322244.R01.S.doc Timescale for action 01/01/07 2. YA6 35 01/01/07 3. YA1 4,5,6 01/02/07 4. YA2 14,12,13 01/02/07 47 Festing Grove Version 5.2 Page 27 assessment. This must included an assessment as to compatibility with others living in the home. The process must include introductory visits. 5. YA6 15 There must be evidence of 01/02/07 regular review of care plans. This must involve consulting with service users. The registered person must ensure that the decision making processes undertaken with service users are recorded. All risks raised by health and social care specialists in relation to the individual care of people must be clearly documented and incorporated into their care plan so as to protect the service user and staff. These must be reviewed regularly. All healthcare and assessment documentation must be up to date and reflect current needs. The organisation must register a manager in respect of this service. 01/02/07 6. YA7 12 7. YA9 12,13 01/02/07 8. YA19 12 01/02/07 9. YA37 8 01/02/07 10. YA39 24 The organisation must develop 01/02/07 their quality audit processes and measure and monitor all aspects of outcomes for service users/stakeholders. Regulation 26 visit information needs development and the staff and service users must be provided with the up to date CSCI reports. Fire risk assessments must be reviewed and up to date. Portable appliance tests must be checked by 30/11/06. DS0000011687.V322244.R01.S.doc 11. 12. YA42 YA24 13 13 01/02/07 30/11/06 47 Festing Grove Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 47 Festing Grove DS0000011687.V322244.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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