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Inspection on 31/08/06 for 49 Victor Street

Also see our care home review for 49 Victor Street for more information

This inspection was carried out on 31st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Victor Street is a well run home with a consistent and well-trained staff group who understand the needs of the service users. The morale within the home is good and that the management style is open and helpful. Three service users and one relatives completed questionnaires, which were sent out by the Commission for Social Care Inspection. All the responses were positive. One relative wrote `my son is happy and I am content`. The service users spoken with also gave positive feedback with comments such as `I like living here`. The atmosphere within the home was friendly and relaxed. Staff were observed to include the service users in all discussion and encouraged them to be a part of the inspection process. The staff were noted to be aware that Victor Street is the service user`s home and were respectful of this. The service user different and diverse needs and strengths are acknowledged in the care planning and risk assessment process and all are encouraged to be as independent as possible. All service users are involved in education, training and one service user is in paid employment. Staff demonstrated a positive value base, were knowledgeable and well informed about individual`s needs and the support they required. Service users are involved in the shopping, meal planning and cooking within the home. The service user feedback was positive about the meals. There are no issues in relation to nutrition. The service users live in a home that is warm, clean and comfortably furnished and a part of the local community.

What has improved since the last inspection?

There is now a quality assurance system in place.

What the care home could do better:

The quality assurance system must now be implemented to review the quality of care provided at Victor Street. There also needs to be evidence that appropriate recruitment and vetting practices are in place to ensure that only suitable people work with service users. The staff files need to be more ordered to ensure that this information is clearly in place. There are also a number of recommendations regarding documents in relation to the health and safety and management of the home.

CARE HOME ADULTS 18-65 49 Victor Street, Stone Staffordshire ST15 8HL Lead Inspector Wendy Snell Key Unannounced Inspection 31 August 2006 13.30 49 Victor Street, DS0000005110.V310622.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 49 Victor Street, DS0000005110.V310622.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. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 49 Victor Street, Address Stone Staffordshire ST15 8HL 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) 01785 615500 RMP Care Miss Lorraine Paula Lawton Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 2006 Brief Description of the Service: 49 Victor Street is a mid terraced house in a quiet residential street in the northern part of the township of Stone. At the front it opens directly on to the pavement, and to the rear, there is a yard leading to a lawn area. Beyond the secure boundary of the property, is the London to Manchester railway line. The home provides accommodation in three single rooms, for three younger Adults [currently all male], who have a Learning Disability. It is the stated intention of the providers, that this shall be in the nearest style to a family domestic setting, as can be achieved for the residents. There is one bedroom, and a shower room [and toilet] downstairs, together with a kitchen/dinette and a lounge/television room. Upstairs there are two further bedrooms and a bathroom, with an adjacent laundry room/staff sleep in room that has a separate toilet, in its own total privacy cubicle. The home operates a no smoking policy, and seeks to maximise the potential for independence of each resident. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on a Thursday afternoon from 1.30pm to 4.30pm. Before the inspection the Commission for Social Care inspection (CSCI) sent out questionnaires to the manager, service users and relatives. The manager, three service users and one relative completed and returned the questionnaires. The views received are reflected in the report. During the inspection three service users, the registered managers and one senior enabler were spoken with. One service user’s file was inspected as were training and recruitment records and other documentation related to health and safety and management of the home. What the service does well: Victor Street is a well run home with a consistent and well-trained staff group who understand the needs of the service users. The morale within the home is good and that the management style is open and helpful. Three service users and one relatives completed questionnaires, which were sent out by the Commission for Social Care Inspection. All the responses were positive. One relative wrote ‘my son is happy and I am content’. The service users spoken with also gave positive feedback with comments such as ‘I like living here’. The atmosphere within the home was friendly and relaxed. Staff were observed to include the service users in all discussion and encouraged them to be a part of the inspection process. The staff were noted to be aware that Victor Street is the service user’s home and were respectful of this. The service user different and diverse needs and strengths are acknowledged in the care planning and risk assessment process and all are encouraged to be as independent as possible. All service users are involved in education, training and one service user is in paid employment. Staff demonstrated a positive value base, were knowledgeable and well informed about individual’s needs and the support they required. Service users are involved in the shopping, meal planning and cooking within the home. The service user feedback was positive about the meals. There are no issues in relation to nutrition. The service users live in a home that is warm, clean and comfortably furnished and a part of the local community. 49 Victor Street, DS0000005110.V310622.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. 49 Victor Street, DS0000005110.V310622.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 49 Victor Street, DS0000005110.V310622.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home has clear assessments of service users needs, which enables the staff to support them appropriately. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The three service users who live in this home have been resident for some time; therefore there have been no recent admissions. The registered manager is aware of the need to ensure that care management assessments are in place prior to admission. One service user’s care file was inspected. The service user has lived at Victor Street for a number of years. The file contained up to date information relating to the support needs of the service user. The senior enabler stated that there was a comprehensive management assessment in place at the time of the service user’s admission and that this information was stored in a separate file. It was evident that the enabler and registered manager had a very good understanding of the service user’s needs. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Service users are able to make decisions about their lives and the assistance they need. Quality in this area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One service user’s file was examined. Care planning information was in place, which outlined how the service user’s support needs were to be met by the staff group. There was evidence that individualised procedures were in place for challenging behaviours with the general focus being on reinforcing positive behaviours. The service user said that he knew staff recorded information in his file and that he was made aware of what was in it. He confirmed that the information regarding how his support needs are met was accurate. There was evidence that the care plan is reviewed and that achievements are recorded. This is good practice. There was evidence that the service user was encouraged to sign a variety of care plan and support information. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 10 Three service users were assisted to complete CSCI surveys. All the service users confirmed that they are encouraged to make decisions and that they are consulted about day to day matters. Staff were observed to interact with service users in an inclusive manner encouraging them to be actively involved in the inspection process. One service user spoke about a planned holiday. He had been given a copy of the holiday details and was also aware of some of the planned route that staff would take to get to the holiday destination. As well as everyday consultations service users also have ‘friendly meetings’ whereby staff and service users discuss how the service could be improved. It was pleasing to note that a number of issues, which the service users had raised, had been actioned by the staff group. One service user’s file was inspected. It was noted that risk assessments were in place, which also incorporated strategies for risk management. The risk assessment process in this home does not restrict or prevent service users from enjoying an independent lifestyle. Pictorial information relating to personal safety and safety in the community was also available within service users files. This is good practice. There was evidence that risk assessments are reviewed. It is recommended that the manager ensures that risk assessments which have been reviewed a number of times are still clearly legible. It is also recommended that the risk assessment in relation to the use of the stairs include what actions will be taken if difficulties are noted. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 All service users access their local community for work, education and leisure and are fully able to express choice regarding their dietary needs. Quality in this area is excellent. This judgement has been made using available evidence including a visit to this service EVIDENCE: Two service users were spoken with about education, employment and community links. One service user confirmed that he was involved in a variety of activities including day services and swimming. He had also worked in a charity shop on a voluntary basis but this had now come to an end. There was evidence that he been encouraged to seek assistance from MENCAP Education and Employment services. He was now waiting for any future opportunities. Another service user had achieved a great deal of independence since moving to Victor Street. He stated that he had two paid jobs, one at a hotel and another at a local supermarket, which he enjoyed very much. He also worked in a voluntary capacity at the local day services. As well as his employment he also enjoyed swimming and aerobics. The service user confirmed that he was 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 12 paid for his work and that he had recently received a positive appraisal from the local supermarket. The staff at Victor Street have close contact with the families of the service users. Two service users confirmed that they have regular contact with their families and that their families can and do visit them at Victor Street. One relative completed a CSCI survey stating that ‘My son is happy and I am content’. It was observed that staff regard Victor Street as the service users’ home. Staff were observed asking and liaising with service users in a respectful way whilst in their home. Staff included the service users in all conversations during the inspection and actively encouraged them to be a part of the process. Two service users confirmed that they have a key for their bedroom and that their privacy is respected. There were appropriate locking devices on the bathroom and toilet door. One service user confirmed that he was able to get up and go to bed when he chose and that there were no restrictions that prevented him from living an ordinary life. It was observed that service users are encouraged to be as independent as possible and to be involved in the day to day running of the home. Two service users said that they are encouraged to be involved in the shopping and menu planning within the home. One service user said that they visit a local supermarket which then delivers the food to the house. He said that some times on a Thursday night they have a take away for tea. It was noted that the service users assist in the preparation of meals and that they are always involved in deciding what meals they should have. The registered manager confirmed that staff have a food hygiene qualification. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users receive personal support in the way that they prefer and require and their medication needs are met by appropriately trained staff. Quality in this area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff were very knowledgeable about the support needs of the service users who live at Victor Street. It was evident that whilst all of the service users are relatively able some service users required more support than others. This was apparent from the interactions and support offered by the staff to service users. It was evident that each service user was treated as an individual with individual needs. The service users were also aware that they all had different strengths and appeared to be both sensitive to and aware of each other’s needs. One service user’s file was examined. Information relating to health needs was recorded. The senior enabler stated that there are a variety of health professionals involved with service users in the home. The registered manager has previously demonstrated that she is aware of when to appropriately contact health services for input. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 14 Medication stored within a locked metal box in a locked cupboard. One service user’s medication and medication administration records were examined and found to be satisfactory. It was noted that the service user received PRN medication, which is given as needed. The registered manager was able to give details of the administration protocol for PRN medication but this protocol was not available for inspection. This protocol should be stored with the medication records at all times. The registered manager stated that all staff who administer medication have received training. The senior enabler confirmed this. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home has appropriate systems in place for dealing with complaints and safeguarding adults. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager stated that there have been no complaints or vulnerable adults issues within the home in the last 12 months. Three service users were supported to complete CSCI surveys. All the surveys confirmed that service users know who to speak to when they are unhappy and were aware of how to make a complaint. It was noted that service users have a copy of the service user’s guide within their files. Information regarding the home’s complaints procedure is recorded within this document. Two service users were spoken with in some depth. Both confirmed that they felt safe living at Victor Street. The safeguarding of adults was discussed with the registered manager and the senior enabler. The registered manager stated that the home has clear vulnerable adult policies and procedures and that some staff had received safeguarding training. It is recommended that all staff receive refresher training in identifying and reporting suspected abuse. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The standard of the environment within this home is good, providing service users with a clean, safe, attractive and homely place to live. Quality in this area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is set amongst similar properties in the heart of Stone and is therefore in walking distance of a range of community facilities. It has been suitably decorated and furnished to present as ‘homely’. All of the bedrooms have been personalised to reflect the individuality of the occupant. One service user confirmed that he had been involved in choosing the décor and furnishings for his room. The registered manager stated that RMP Care have a part time maintenance man who assists with decoration and repairs. It is recommended that the manager complete a redecoration plan for this home. There is an enclosed back garden with seating areas for service users and staff. The home was generally well maintained and clean. The feedback from the service user surveys was positive in relation to the cleanliness of the home. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 17 Service users are encouraged to have some responsibility for general cleaning and hygiene within the home. This home does not have a dedicated laundry room. It does however have appropriate washing and drying facilities, which the service users are encouraged to use. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Victor Street has an appropriately trained, supervised and competent staff team who are able to meet service users needs. However, shortfalls in recruitment and vetting practices potentially expose service users to abuse. Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One senior member of staff was spoken with about her experience and the training she had received. The senior worker had worked for RMP Care Homes for nine years and was very knowledgeable about the support needs of the service users. She had received all the mandatory training and had achieved NVQ3. The statement of purpose indicates that more than 50 of the care staff have achieved NVQ2. This exceeds the guidance set out in the National Minimum Standards. The registered manager stated that there are a group of staff who work predominantly in this home and therefore provide the service users with consistency of care. Service user in this and other RMP Care homes also benefit from support of a pool of a staff who are known to the service users and who can deputise for each other at short notice, rather than having to bring in agency staff who would be unknown to the service users. The close proximity of homes enables an interchange of staff should any emergency arise. It also allowed for use of “internal” bank of available staff with the 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 19 benefit for service users, that only in the most exceptional circumstances, would they have to accept people into the home that they did not already know. The senior enabler confirmed that she has regular supervision. Examination of staff files revealed that a supervision contract was in place but there was no evidence that regular supervision sessions are recorded. This was discussed with the registered manager who agreed that this was an area, which needed to be improved. Three staff files were looked at to examine the home’s recruitment and vetting processes. Two files had the correct information. One file did not contain the appropriate references for a member of staff. The registered manager stated that they might have been misfiled. The staffing files were not ordered and recruitment and vetting information was not easily accessible. Evidence that references are in place must be forwarded to CSCI. It is recommended that the filing system be reviewed to aid ease of reference. It is also recommended that the registered manager reviews the letters sent out to referees to include requesting information relating to any disciplinary matters that prospective employees may have been involved in. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Service users who have a short stay at Victor Street benefit from a well run home with effective systems. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered manager has several years experience of managing learning disability care homes. She is the manager of this home and one other RMP care home, which is situated on the other side of the road. Discussions with a service user and observations of how the manager interacted service users and staff indicated that she is very approachable and has an open and inclusive management style. The registered manager confirmed that she has the appropriate qualifications to manage a care home as well as being an NVQ assessor. Quality assurance was discussed with the registered manager who stated that a quality assurance tool had been developed but not yet implemented. It was evident that service user views are regularly sought and acted upon. However, 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 21 there is no system in place to record the many developments, which have clearly happened at Victor Street. The manager must now ensure that a quality assurance system is developed and used which clearly identifies how the views of service users and other stakeholders inform the annual development plan for this home. The fire records indicate that service user’s health and safety is protected by satisfactory fire drills and fire safety checks. Within the fire file there was pictorial information for service users, which highlighted what they needed to do in a fire. Two service users confirmed that fire drills do take place and that they did know what to do in the event of a fire. There was evidence that gas serving has taken place. The registered manager spoke with a director of RMP Care Homes regarding the electrical servicing of Victor Street. The director stated that the servicing was up to date. It is recommended that proof of this is forwarded to the CSCI. The home has a first aid box. The registered manager confirmed that there is always a staff member on shift who is qualified in first aid. The home had up to date insurance cover. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 22 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 x 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x 3 x 2 x x 3 x 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Timescale for action 19(1)(b)(i) The manager must forward proof 11/09/06 that references are in place for the member for staff identified at the inspection. All reference must be kept on file. 24(1)(a) The manager must establish and 01/12/06 maintain a system for reviewing the quality of care provided within the home. Regulation Requirement 2 YA34 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 Refer to Standard YA9 YA9 YA20 YA23 YA24 Good Practice Recommendations The risk assessments should be reviewed to ensure that they remain easy to read after they have been reviewed. The risk assessment in relation to the use of stairs should outline actions to be taken when problems arise. PRN protocols should be stored with medication at all times. All staff should have refresher vulnerable adults training. The manager should forward a redecoration plan to the CSCI. DS0000005110.V310622.R01.S.doc Version 5.2 Page 24 49 Victor Street, 6 7 8 9 YA34 YA34 YA42 YA36 Staff personnel files should be ordered to ensure documents are easily accessible. The manager should consider ensuring that letters sent to referees regarding potential employees includes information regarding any disciplinary history. The manager should forward proof that the electrical servicing is up to date and satisfactory. Staff supervision sessions should be recorded. 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 49 Victor Street, DS0000005110.V310622.R01.S.doc Version 5.2 Page 26 - 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. 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