Inspection on 06/12/06 for 484 Halifax Road

This inspection was carried out on 6th December 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 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

484 Halifax Road 01/06/09

484 Halifax Road 05/12/08

484 Halifax Road 01/02/06

484 Halifax Road 22/02/05

484 Halifax Road 27/10/04

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

CARE HOME ADULTS 18-65 484 Halifax Road Bradford West Yorkshire BD6 2LH Lead Inspector Linda Trenouth Key Unannounced Inspection 6th December 2006 09:30 484 Halifax Road DS0000019914.V310301.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 484 Halifax Road DS0000019914.V310301.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. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 484 Halifax Road Address Bradford West Yorkshire BD6 2LH 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) 01274 676466 01274 676466 carolyn.stafford@bhcg.nhs.uk Brunel & Family Housing Association Limited Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: Halifax Road is a Brunel Support Works home situated on the outskirts of Bradford. The home is registered to provide long-term personal and nursing care for up to 6 adults with learning disabilities. Staff are employed by Bradford District Care Trust. The building is a large three storey terraced house. Accommodation is provided on two floors, with 6 single bedrooms, three bath/shower rooms and a domestic style kitchen, living and dining room. Halifax Road has a garden at the front of the house and a car parking area to the rear of the building. Local shops and bus routes are within easy access. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example, Choice of Home and “Lifestyle.” An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent,” “good”, “adequate” and “poor.” The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The site visit was unannounced by one inspector and took place over one day for a period of approximately 6 hours. The inspection also includes gathering of information and evidence prior to and after the visit to decide the overall judgement. The inspector met with three residents and talked to the manager and the staff. The main purpose of this inspection was to make sure that the home continues to provide a good standard of care for the residents. The methods used at this visit included looking at the organisational records, observing working practices, and talking to residents and staff. A tour was also made of the premises. The home returned the pre inspection questionnaire, which provided information about staffing and residents at the home. The questionnaire also requests the fees that the home charges. The fees for the service are £427.28 per week. Comment cards were left at the home to provide residents and visitors with the opportunity to comment on the service and were also sent out to Social and Health Care Professionals. One questionnaire was returned in time for completion of this report. The findings from this questionnaire are included in the report. Feedback was given to the manager Phillip Holden at the end of the inspection. Requirements and recommendations made during this visit, and outstanding from previous inspection visits can be found at the end of the report. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There has now been an appointment of a permanent manager to the home. The home has had an unsettled period with different managers and changes to staffing. This has caused a lack of continuity to residents and support to staff. It is hoped with the appointment of the present manager the staff will have consistent leadership and support to better enable and support them to provide a good quality of care to the residents. Residents’ meals are now planned and a menu displayed in the home. The staff discuss with individuals their particular likes and dislikes, and encourage residents to suggest different foods and meals to make a varied and interesting menu. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 7 The home now has an appropriate washer for the safe laundering of clothes and has provided evidence of safe electrical systems in the home. The kitchen has been deep cleaned and additional cleaning is planned for the future. A mobile phone has now been provided for staff to use when they out with residents in case they need to contact for support or assistance. What they could do better: It was good to see that all the residents have individual, “licence agreements” however they were not signed and some charges were omitted. The agreements must be signed by both parties and must include all additional charges that will be made such as minibus leasing and minibus fuel charges. The care plans and resident’s information were very detailed but difficult to manage, and were not adequately reviewed. A simplified system must be introduced and regular reviews must take place. Some areas of the home have deteriorated into a poor state and it is clearly not a comfortable environment for people to live in. The home needed urgent redecoration and refurbishment. Lighting levels, lockable facilities, and locks on bedroom doors also needed review. Monies have been identified to provide refurbishment although the manager wasnt clear when this would happen he was aware that the money identified was from this years budget and had to be used by the 31st of March 2007. The home was not to a good standard of cleanliness during the visit. Cleaning is presently undertaken by the staff. The care staff cannot support residents and effectively clean the home. A separate cleaning role must be provided. Medication guidelines for the administration of PRN medication needs to be reviewed to ensure that all staff administer this medication consistently and in the best interests of the individual. Staff must also ensure they provide full detailed daily records to support the administration of this medication. Whilst the home did provide safe staffing levels at the home, the registered person must review levels to ensure all residents’ social needs are met. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 8 There were insufficient staff records to decide whether staff had been safely recruited or not to the home. The recruitment records must be available and accessible at the home at all times. The home has been without a registered manager for some time, a permanent manager is now in post and must make an application to be registered with the CSCI. 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. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 9 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 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 10 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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents and their relatives have copies of the service user guide to make sure they have information about the service that is provided. Whilst the contracts have been issued to all residents they have not been supported to understand and agree to this important documentation. EVIDENCE: The manager confirmed that the residents and relatives have been sent a copy of the service user guide. There were no new admissions to the home since last inspection therefore it was not possible to confirm the content of the assessment information prior to placement. All residents had copies of their “licence agreement,” however they were not signed by the resident or their relative or advocate, the only signature on 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 11 these contracts was a representative from Brunel Housing. The contracts also did not include any reference to the charges that were being made for the minibus. Each resident is charged approximately £7 per week for the leasing of the minibus. In addition to this there are charged for diesel on a weekly basis of approximately £6.50 to cover the cost of fuel. The home must ensure that all arrangements or financial commitments are fully agreed to and that residents have the support of an advocate or relative to make this decision. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans and resident information was very detailed but difficult to manage, and was not adequately reviewed. Residents are encouraged to make decisions and take risks in their day-to-day lives. EVIDENCE: The care plans were reviewed and were found to be bulky and cumbersome. There was good detail within the care plans but the style of format meant that information was difficult to find. The acting manager of the home was designing a simplified plan which would be easily available to staff and other records stored would then be for reference only. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 13 The organisation had attempted to introduce person centred planning, but the care plans are still clinically orientated and do not adequately assess the individual in terms of their individual aspirations, interests and social care needs. The communication and daily record provided good evidence of the support of individual needs. In the case tracking all the care plans had been updated in November unfortunately this was with the resident and staff only and there was no apparent involvement of the relative or an advocate. From discussions with staff and review of records it was evident that the home holds residents’ forums and encourages residents to have their say in the running of the home. Individuals are also encouraged to help around the home, express their opinions and there were many examples of their participation in daily decision-making. The present care planning has begun to involve the resident in decision making in their lives, when the organisation fully embraces person centred planning this should encourage a greater acknowledgement of the aspiration, interests and hobbies of the individual. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 14 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. Residents have opportunities to go on regular trips out and are encouraged to develop different skills. Activities in the home could improve with better staffing levels. EVIDENCE: The condition of the building is poor but staff have created a home for residents and the people were clearly relaxed and content. All residents are encouraged to help around the home. This includes dusting, vacuuming, washing up, emptying bins, making beds, and cleaning bedrooms. The home has a fish tank with one of the residents responsible for feeding the fish and the birds in the garden. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 15 Residents attend various day care services and enjoy some activities with staff, but these tend to be group activities. Staff said that they were unable to involve people in, as many individual activities as they would like, as there were not adequate staffing levels at the home. Staff gave examples of going out on visits to Manchester and other areas where all residents will be put on the minibus because it was not possible to split the group. The manager must staff the home to ensure some flexibility and support of individual residents’ needs. This has been raised on previous inspections. Residents meals were planned and displayed in the home, discussion was held about their particular likes and dislikes, and staff encouraged residents to suggest food and meals to make a varied and interesting menu. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 16 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. In general the manager and staff ensured that the residents health care needs were met. EVIDENCE: The health care records were good and reviewed all residents’ health care needs. The staff must ensure that all residents weights are regularly recorded where this is part of their care plan. The health care professional comment card returned confirmed that they felt the staff at the home had a good understanding of the care needs of the residents and that they supported them in their health care. The medication was well stored, and records were satisfactory. The home uses a monitored dosage system alongside PRN (Prescription Required as Needed) medicines. A list of authorised staff to administer medication was recorded with specimen signatures, was evident within the medication records. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 17 Concerns were raised regarding inadequate guidance to staff about the administration of PRN medication. This was where medication is used as a behaviour control. Staff did not record enough detail or information in residents daily notes to clearly explain what had lead to its use. Staff must have clear guidance so that a consistent approach is used in the administration of such medication and to ensure it is in the best interests of the individual. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are safeguarded from abuse. EVIDENCE: Staff have undertaken adult protection training and showed a good awareness of the recognition of abuse. Polices and procedures are available to all staff. Residents and relatives have a copy of the service user guide, which contains the complaints procedure. Carers and residents meetings have commenced. Residents have a named nurse and named key worker who works alongside staff to encourage individuals to express their opinions and raise concerns. Staff said that all residents were assisted with their personal allowance. Individuals have their own bank accounts. Staff confirmed that they helped residents withdraw money directly from their accounts or raised this money from petty cash, which was then paid back via the resident’s bank account. Two staff signed for any transactions and any purchase/ withdrawal over £50.00 had to be authorised by the manager. 484 Halifax Road DS0000019914.V310301.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, and 30. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The residents live in a home where decoration and furnishings are not of a good quality, and adequate provision for their privacy is not ensured. EVIDENCE: Some areas of the home are looking in a poor state and it is not a comfortable environment for people to live in. The carpets are dirty and worn, wallpaper was hanging from walls, and some areas were in need of urgent improvement. The manager from Brunel confirmed that money has been allocated to decorate and carpet the hallway and bedrooms. The carpet in the lounge was dirty and others were in need of cleaning or replacing. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 20 Concerns were raised about a ground floor bedroom where lighting levels were not adequate and this needed addressing. The door to the basement should also be locked. One resident had requested a lock fitting to his door in his review but this had not been done. It was also a concern that other residents did not have a lock fitted to their bedroom doors. All residents must have a lock on their bedroom. The locks must meet health and safety requirements and therefore consultation with the fire officer as to the correct type is required. Concerns were also raised about access to the basement; it was recommended that the door be fitted with a lock at the top of the stairs to prevent possible accidents. Monies have been identified to provide refurbishment although the manager wasnt clear when this would be, he was aware that the money identified was from this years budget and had to be used by the 31st of March 2007. To adequately clean the home cleaning hours must be put into place and these must be separate from the caring and support role. The manager said that he had requested this and was hopeful that this was going ahead. 484 Halifax Road DS0000019914.V310301.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, 34, 35, and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff at the home have good training opportunities, regular supervision and team meetings. Staffing levels at the home are not sufficient to meet the needs of residents at the home and therefore effect the quality of their day-to-day experience. EVIDENCE: The home has been through a period of change in the last year with temporary managers in place. This has effected the stability and leadership of the home for residents and staff. The manager said that night staffing hours have been increased at the home to two waking night staff but with no increase in overall budget. This has reduced the daytime allocation of staffing hours. Often there are only two members of staff on duty and this directly impacts on the scope of what activities individuals can realistically undertake. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 22 The manager and staff said there is a big difference in the quality of service that is provided when three staff are on duty. Residents have more opportunities to go out in smaller groups and it is possible to do more individual work. From available staff records it was not possible to decide if staff were recruited safely to the home, some staff records available were incomplete. Staff spoken to and audited had been employed in the organisation for some time and there was no new recruitment to the home. The most recent staff changes at Halifax Road had been transfers from other homes within the Bradford District Care Trust. 484 Halifax Road DS0000019914.V310301.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): 27, 39 42 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst the home now has a permanent manager, which will provide more consistency and stability. The manager must register with the CSCI to be fully effective in their role and to be able to support staff and residents. EVIDENCE: Carers and residents meetings have now commenced. The manager said he hopes to develop questionnaires in the future. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 24 A recent visit from the fire officer had identified concerns regarding the home in terms of fire protection and safety. It was confirmed that all the recommended work had now been completed. The staff and residents had undertaken some fire instruction and training. Records of regular testing of the fire alarm equipment and emergency lighting had however not been completed. Fridge and freezer temperatures were recorded and the annual small electrical appliance testing had been completed. The storage of confidential records was a concern as care records and personal details are held on the ground floor where they can be accessed by residents and visitors. The storage of these records must be reviewed. The manager said he would arrange a lockable cupboard for records. The regulations governing the home require that regular visits take place by the registered persons or their representative. This is to support the manger staff and residents in the home. These visits have been taking place regularly and highlighted area of support and maintenance that was needed and some areas put into action. 484 Halifax Road DS0000019914.V310301.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 3 2 3 3 x 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 3 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 3 x x 3 3 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 26 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001, and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation 5 Requirement Contracts must be signed and include all additional charges that will be made i.e. minibus leasing and fuel charges. The registered person must ensure care plans are reviewed regularly. The plans should be organised so they can become effective working documents. Previous timescale 30/04/06 not met. Reviews of the care plans must include relatives, advocates, or the residents’ representative. There must be clear guidelines for staff to regarding the administration of medication. The registered provider must make sure the home is decorated and the stair carpet must be replaced. Previous timescale 30/04/06 not met. Bedroom doors must have a lock for the residents’ use, which meets health and safety standards. The registered person must review the staffing levels to DS0000019914.V310301.R01.S.doc Timescale for action 01/03/07 2. YA6 15 01/03/07 3 4 5 YA6 YA20 YA24 15 13 23, 16 01/03/07 01/03/07 01/03/07 6 YA25 23 01/03/07 7 YA33 18 01/03/07 484 Halifax Road Version 5.2 Page 27 ensure residents’ needs are met. Previous timescale 30/04/06 not met. 8 YA34 19 The registered person must make available for inspection all recruitment documentation. (Timescale of 31/08/06 and 30/04/06 not met. The registered person must submit an application for the manager to be registered with the CSCI. Previous timescale 30/04/06 not met. 01/03/07 9 YA37 8 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard YA10 YA19 YA25 YA32 YA39 YA42 Good Practice Recommendations Records must be stored appropriately ensuring confidentiality is maintained. The registered person should make sure residents’ weight is monitored regularly. Lighting levels to ground floor bedroom should be improved. The registered person should ensure 50 of care staff in the home achieve a care NVQ 2. The door that provides access to the basement from the ground floor should be fitted with a lock to ensure safety. The manager must ensure that the fire system is tested regularly. 484 Halifax Road DS0000019914.V310301.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 484 Halifax Road DS0000019914.V310301.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. 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