CARE HOME ADULTS 18-65
Almond Close (49) 49 Almond Close Bellfields Estate Guildford Surrey GU1 1NW Lead Inspector
Lisa Johnson Unannounced Inspection 20th March 2007 09:30 Almond Close (49) DS0000013506.V330006.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 Almond Close (49) DS0000013506.V330006.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. Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Almond Close (49) Address 49 Almond Close Bellfields Estate Guildford Surrey GU1 1NW 01483 575806 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) H4037@mencap.org.uk Royal Mencap Society Ms Alison Jelley Care Home 8 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (1) of places Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 19 - 65 YEARS OF AGE one named person may be over the age of 65 Date of last inspection 4th August 2006 Brief Description of the Service: 49 Almond Close, Guildford is a detached property developed to provide accommodation for eight adults with learning disabilities. The home is set in a road close of similar properties. All rooms are for single occupancy, none with en-suite facilities. The home offers a sitting room equipped with television and music systems, a dining area, kitchen, and utility room for laundry and toilet and washing facilities. There is a garden to the rear of the property and some off road parking to the front. The registered providers are the MENCAP organisation and the Local Authority owns the premises. The weekly charges range from £62.35- £94.45. Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The site visit was unannounced and took place over six hours commencing at 09.30am and finishing at 4.30pm. The visit was carried out by Mrs L Johnson, Regulation Inspector. The inspector spoke with four service users to gain their views on the care provided. A full tour of the premises took place. Care plans, staff training records, staff files and policies and procedures were sampled. The inspector spoke to three members of staff. The inspector would like to thank the staff and service users for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection?
Since the previous visit a number of environmental improvements have been made including redecoration in the communal areas. Identified repairs have been completed in the kitchen and to carpets. Carpets in the lounge have been cleaned and one individual has acquired a new bed. The inspector was informed that the maintenance log is maintained. Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 6 The home has responded to two recommendations made at the previous visit. Staff spoken with stated that arrangements are in place for them to attend training in equality and diversity. Three members of staff spoken with confirmed that they have attended safeguarding adults training. During this visit all hazardous cleaning items were observed to be appropriately stored. The employers liability insurance has been renewed and a gas safety record was available and electrical testing of equipment had been completed. The home has responded to a recommendation by supplying room numbers to bedroom doors. What they could do better:
It was recommended that copies of any pre- admission assessments conducted by the home should be made available with service users’ records for viewing. Service users and/or their representatives should sign to agree their care plans to ensure they are fully involved and consulted. A requirement was made that any medication that is hand transcribed by staff on to the medication administration record from the prescription must be signed by the author and it was recommended that this should be checked by a second member of staff to ensure the health, wellbeing and safety of service users are protected by the home’s medication policies and practices. It was recommended that copies of the home’s complaints procedure be provided to service users’ relatives and representatives to ensure that they have the information they require should they wish to raise any concerns. Improvement is required in modernisation and maintenance of the bathrooms and a light flex was observed to be hanging in the corridor and one bedroom had a pervading odour. These matters must be attended to, to ensure that service users have comfortable communal areas to use. The company is advised to review the present staff sleeping in arrangements in the office. Due to the absence of the registered manager at this visit the staff recruitment files could not be viewed. It is required that the home confirms in writing to the Commission for Social Care Inspection that they have a robust recruitment policy and practices in place and that arrangements are made for access to the personal files for access at the next site visit to ensure that service users are protected by the home’s policies and procedures. A recommendation was made that a staff-training schedule is maintained for viewing. Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 7 At the previous visit a requirement was made that the responsible individual undertakes monthly quality visits. This matter has not been completed and therefore a further requirement was made that this matter is attended to. This is to ensure that the home is run in the best interests of service users. It is recommended that the company update their policies and procedures. One bathroom was observed to have an exposed light bulb and flex hanging from the ceiling. It was required that an appropriate covering is provided to ensure the health, welfare and safety of service users. 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. Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 8 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 Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of service users are assessed prior to admission to the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide. The inspector was informed that these are issued to all individuals in the home. A copy of the Service User Guide was examined but did not include the name of the manager and a recommendation was made that this information is recorded. The company has an admission policy in place. There have been new admissions to the home since the previous visit. Evidence was available that community care assessments had been obtained. However there was no evidence to indicate that the home had completed their own pre- admission assessments. Therefore a recommendation was made that copies of preadmission assessments should be maintained with service users’ records to ensure that their needs can be fully met. Almond Close (49) DS0000013506.V330006.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 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with an individual care plan, which records their individual needs and goals. Service users are supported to make decisions about their lives with assistance and are supported to take risks as part of an independent lifestyle. EVIDENCE: Three individual care plans were sampled. Each service user has a completed care plan, which includes, personal, health, emotional, spirituality, culture relationships, domestic and leisure needs. The home is in the process of introducing person centred plans. The inspector was informed that a person centred planning meeting had been conducted for one individual who confirmed that she had attended this meeting. Another individual also said that he had the opportunity to attend his review meetings. It was observed that service users and/or their representatives had not signed their care plans to confirm their agreement. Therefore a requirement was made that this is completed to ensure that service users and/or their representatives are fully consulted.
Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 11 Staff spoken with had good understanding of the service users’ care plans and are involved with care plan review meetings. One new member of staff said that the care plans were brought to her attention during her induction programme. Service users are consulted and supported to make decisions about their lives with assistance where required. One individual spoken with confirmed that they manage their own finances with some support. Two service users spoken with said they have the opportunity to attend meetings in the home and one individual said, “staff ask me about things that I would like to do”. Service users are supported to take part in having an independent lifestyle. Comprehensive risk assessments and guidelines were included with each individual plan, which were regularly reviewed and updated. One individual said that they go out independently and use public transport, which was also confirmed by the individual’s key worker. Other plans sampled included bathing and domestic skills. Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 12 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 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a range of appropriate activities and engage in a range of leisure activities. Service users are supported to take part in the local community and the rights and responsibilities of service users are respected. The home is able to demonstrate that service users are provided with a well-balanced and nutritious diet. EVIDENCE: The home provides a wide range of activities for service users to attend. During this visit service users were busy attending a number of activities. Service users are supported to access a range of activities. One individual said,” I work in Sainsbury’s”. Another individual told the inspector that they attend a day service facility. Service users enjoy a range of leisure activities, including visits to the pub, theatre trips and going shopping. One person said, “I go to church on Sundays”. During this visit service users were observed to be involved in household activities including cleaning, vacuuming and one individual was observed assisting with preparing the evening meal. Another individual said, “I help to keep my room clean and tidy”.
Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 13 Three service users spoken with maintain links with their family and friends whom they visit and one service user said that he was going away on holiday with his family. One individual said that he has access to the phone to speak to his family. Good interaction was observed between staff and service users and their choices were respected. Some service users were observed choosing and making their own breakfast and were able to access the kitchen to make drinks. One individual said that they were able to get up when they wished. Service users are provided with a key to their room and where individuals have not chosen to have one, this was recorded in their care plan. Service users have the opportunity to choose their meals based on their individual preferences. The menu is discussed with service users on a weekly basis. The main meal is provided in the evening. The menu is provided in picture format, which enables service users to know what the evening meal is for a particular day. Service users spoken with were happy with the meals provided and comments included “Great” and “Good”. Choices are accommodated and records are maintained of any alternative meals provided. Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 – 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that service users receive personal support in the way they prefer. Service users’ physical and health needs are met and they are in the main protected by the home’s medication administration procedures, with one matter identified needing attention. EVIDENCE: Service users’ care plans identified their likes and dislikes, preferences and routines. Staff were observed to assist and give guidance to service users with all aspects of care. Two individuals spoken with said they are able to make a preference about preferred times of getting up. There was evidence to suggest that service users are supported to access health care professionals, which included the General Practitioner, chiropody and the dentist. Records were maintained of all health care professional consultations. The inspector spoke with one individual who said, “I visit the dentist” and another individual stated, “I visit a doctor and I am seen by a nurse”. The medication administration policies and procedures were examined. Photographs of individuals were maintained with their records. All medication administered was signed for. A homely remedies protocol was in place. Medication is obtained from Boots chemist who conducts staff training. One individual had been prescribed antibiotics out of hours and this had been
Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 15 hand transcribed by staff on to the medication administration record but had not been signed by the author and another individual was receiving vitamin tablets and this medication card was also not signed by the author. A requirement was made that medication which is hand transcribed must be signed by the author; it was also recommended that this should be checked by two staff to ensure that service users are protected by the home’s medication administration policies and practices. Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that the views of service users are listened to and acted upon. Service users are protected from abuse. EVIDENCE: The home has a complaints procedure in place and the inspector was informed that a copy is made available to all service users. The deputy manager stated that a record book is maintained to report any complaints or concerns and none have been received since the previous visit. Two individuals spoken with knew whom they could talk to if they were unhappy. It was recommended that a copy of the complaints procedure be made available to relatives and/or representatives should they wish to raise any issues. Three service users spoken with spoke positively about the home and comments included “This is a great house; “Its friendly” and “the staff are kind and helpful”. The local authority multi agency safeguarding adult procedures were available and the company has its own whistle blowing procedure. Three staff spoken with confirmed that they had attended up to date training in safeguarding adults from abuse and one individual spoken with was clear in her responses as to the action she would take if she witnessed any abuse. Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users in the main live in a homely, comfortable safe and clean environment with some matters identified that need attention. EVIDENCE: Since the previous visit some of communal areas have been redecorated, tiles have been replaced in the bathrooms and some of the bedrooms have also been repainted. The carpets have been cleaned in the sitting room. There is a large open plan sitting/dining room, which has been complimented with new furniture. One service user spoken with stated that he had been involved with choosing this furniture. There was a large wide screen television available. Photographs of work that had been completed by service users were observed on display in the dining area. One individual has acquired a new bed and repairs have taken place to the kitchen units. However bathrooms need modernisation and a floor needs replacing in one bathroom. A toilet seat was broken in one bathroom and a light flex was observed hanging in the corridor. These matters must be attended to, to ensure that service users have safe, well-maintained and comfortable communal areas to use.
Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 18 The staff office is used as a sleep in facility for staff. The inspector was informed that council planning permission has been gained to extend this area, however this work may take up to a year to complete. Due to the size of the office staff sleep on a fold up bed. The company is advised to respond to this matter to ensure that staff are provided with suitable facilities. The home was clean and hygienic. Suitable hand washing facilities were in place and separate laundry facilities were available. Three bedrooms were viewed during this visit, which were comfortable and personalised with individual’s belongings. One individual said, “I like my bedroom and I help keep it clean”. However, one bedroom had a pervading odour with a chair needing cleaning or replacing. It is required that this matter is attended to with a more suitable covering to be provided to ensure that service users have clean and comfortable bedrooms. Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty were adequate to meet the needs of residents. One matter needs attention to ensure that service users are protected by the home’s recruitment policies and procedures. Service users are in the safe hands of the staff that were competent and trained to do their jobs. EVIDENCE: During this visit there were two members of staff on duty with a third member of staff who arrived on duty before lunch. The duty rota was examined which indicated that there are always two members of staff on duty during the day. At nighttime one member of staff sleeps in. Staff spoken with stated that the present staffing levels meet the needs of the current service users, as the service users are mainly independent. Arrangements are in place if extra staff are required and a manager is available on call after hours if assistance is required. The registered manager was unavailable during this visit and the staff training records and recruitment files could not be accessed, although three members of staff spoken with confirmed that they have received up to date mandatory training including manual handling, fire awareness, safeguarding adults from abuse and first aid. Other training provided included challenging behaviour,
Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 20 epilepsy and one member of staff stated that she had received training in diabetes awareness. The inspector was informed that the company is now providing training in culture and diversity. The home supports staff to complete National Vocational Qualifications and the deputy manager stated that 75 of staff have obtained National Vocational Qualifications (level 2) or above. A copy of the General Social Care Code of Conduct was present and staff spoken with said that this document had been brought to their attention. It is required that the home confirms in writing to the Commission for Social Care Inspection that they have a robust recruitment policy and practices in place and that arrangements are made for access to the personal files for viewing at the next visit to ensure that service users are protected by the home’s policies and procedures. A recommendation was made that a stafftraining schedule is maintained for viewing. Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager has the appropriate experience to manage the home. Further improvement is needed to ensure that the home is run in the best interest of residents. The health, welfare and safety of residents are mainly protected with one issue identified needing attention. The service is able to demonstrate that service users benefit from a well run home. EVIDENCE: There is a registered manager in post and the inspector was informed that the manager is completing the Registered Managers Award. Staff spoke positively about the management support provided in the home and regular staff meetings are held. The inspector was informed that quality assurance questionnaires are provided to service users and that they are to be updated again in the near future. Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 22 At the previous site visit records were not available in the home for the monthly quality visits. These reports were still not available during this visit and the inspector was informed that to their knowledge visits have not been conducted since September 2006. Therefore a further requirement was made in respect of this matter to ensure that the home is run in the best interest of service users. A range of policies and procedures was available. One member of staff stated that new procedures are brought to their attention. Some of the policies observed had not been reviewed for a few years and a recommendation was made that attention to this matter should be considered to ensure that information is up to date. A number of health and safety records were sampled including fire records, which indicated that fire alarms are regularly checked and fire drills are up to date. Water temperature records were maintained. An emergency contingency plan had been completed and bedroom doors have been supplied with numbers so they could be identified by the fire services in the event of a fire. Accident records were maintained for service users. Only one accident had been recorded since the previous visit. The cupboard containing cleaning materials was stored appropriately. It was observed in the downstairs shower room that there was an exposed flex and light bulb uncovered. It was required that this matter is attended to, to ensure the health and safety of service users. Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 24 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 YA6 Regulation Requirement Timescale for action 20/05/07 2 YA20 3 YA24 15(2)(a)(c)(d) The registered person must ensure that service users and/or their representatives agree to their individual care plans. 13(2) The registered person must ensure that medication that is transcribed on to the medication administration record is signed by the author. 23(2)(b) a) The registered persons must ensure that the floor is replaced in one bathroom and the toilet seat is repaired. 27/03/07 20/07/07 4 YA30 23(2)(d) 5 YA34 17 (3)(b) & 26 b) The light fitting in the corridor must be attended to. The registered person must 02/04/07 ensure that the bedroom with a pervading odour be attended to. a) The registered person must 20/04/07 confirm in writing to the Commission for Social Care Inspection that there are robust recruitment polices and practices in place. b) Arrangements must be Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 25 6 YA39 17 & 26 7 YA42 13(4)(a)(c) made for access to the staff personal files. The registered person must ensure that monthly quality visits are undertaken and the reports are to be made available in the home at all times. (Previous requirement 11/08/06 not met) The registered person must ensure that the light in the downstairs shower room is attended to. 20/04/07 27/03/07 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. Refer to Standard YA2 Good Practice Recommendations It is recommended that the home maintain copies of any future pre-admission assessments carried out by the home, and these are maintained with service records for viewing. It is recommended that a copy of the complaints procedure is provided to relatives and/or representatives should they wish to raise a concern. The registered person should consider implementing a staff-training schedule that is accessible for viewing. The company should consider updating their policies and procedures. 2. 3 3 YA22 YA35 YA39 Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Almond Close (49) DS0000013506.V330006.R01.S.doc Version 5.2 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!
