Inspection on 06/12/06 for 56 St Saviours 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 (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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

56 St Saviours Road 20/10/09

56 St Saviours Road 09/11/05

56 St Saviours Road 11/05/05

56 St Saviours Road 12/10/04

56 St Saviours Road 10/05/04

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

CARE HOME ADULTS 18-65 56 St Saviours Road St Leonards-on-sea East Sussex TN38 0AR Lead Inspector Caroline Johnson Unannounced Inspection 6th December 2006 10:30a 56 St Saviours Road DS0000021338.V318675.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 56 St Saviours Road DS0000021338.V318675.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. 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 56 St Saviours Road Address St Leonards-on-sea East Sussex TN38 0AR 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) 01424 443657 Sussex Autistic Community Trust (Care Services) Limited Ms Jill Coker Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That only service users with an autistic spectrum disorder may be admitted. The maximum number of service users to be accommodated must not exceed 3 (three). The people accommodated will be between the ages of 18 (eighteen) and 65 (sixty-five) years of age on admission. 9th November 2005 Date of last inspection Brief Description of the Service: 56 St Saviours Road is a semi-detached property situated in a residential area of St Leonards on Sea. The town centre with its shops and railway station is approximately one mile away. Resident accommodation is on two floors with a lounge and dining room on the ground floor and bedroom accommodation situated on the first floor. The home is registered to accommodate three adults with a learning disability who have an autistic spectrum disorder. The home is one of four homes in East Sussex that are run by The Sussex Autistic Community Trust (care services) Ltd. The range of fees as of 27 November 2006 is from £1,231 to £1,250. Additional charges are made for toiletries, chiropody, hairdressing and magazines. The home makes inspection reports available upon request and there is a copy available in the home to read at all times. 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process a site visit was carried out on 6 December 2006. This visit lasted from 10.30am until 5.00pm. There was an opportunity to spend time in private with one of the residents and to meet briefly with the other two residents. All communal areas of the building were seen along with one of the bedrooms. The registered manager was on duty at the time of inspection and time was also spent with one member of care staff. A wide range of records were examined over the course of the day including two care plans and risk assessments, staff recruitment records which also included details of training and supervision, menus, fire safety records and health and safety documentation. In advance of the site visit comment cards were sent to the home for distribution to the residents. Two of the residents did not appear to fully understand the questions but gave some positive feedback. A third resident responded very positively to all questions and commented ‘I am happier living at St Saviours than where I was before, it is near town so I can be more independent and quiet at night so that I can get a good rest’. Following the inspection attempts were made to contact the relatives of the residents to seek their views on the quality of the care provided in the home. One relative was spoken with and they stated that they are 100 happy with the care provided. They also stated that they enjoy the opportunities provided by the home to meet up with the staff team and the parents of the other residents. What the service does well: What has improved since the last inspection? 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 6 All the requirements made at the last inspection have been addressed. The manager is now studying for NVQ (National vocational qualification) at level four and a member of care staff is studying for level three. On completion of this course another carer will commence training. There are clearer arrangements in place for the management of residents’ finances. There are still some vacant staff hours but they been deliberately left vacant so that the home now uses three regular relief staff instead. Having this in place means that they can be more creative with the activities programme using a few hours as and when needed and activities can be arranged more spontaneously. The trust has completed the updating of policies and procedures manual and the home are now working their way through the manual ensuring that all documents are relevant to the home. In relation to one resident a staff member has carried out extensive research into their cultural and religious festivals and observances and this has been discussed with the resident’s relatives to check for accuracy. The home is to be commended for the work carried out in this area. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 56 St Saviours Road DS0000021338.V318675.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 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Measures were taken by the home to seek the views of a prospective resident prior to admission and to ensure that they had detailed information about the home prior to making a decision about admission. However, the home’s pre admission assessment procedures should be followed regardless of whether it is an internal transfer or an admission from outside of the organisation to ensure the placement is suitable. EVIDENCE: One resident has been admitted to the home since the last inspection. The move was seen as an internal transfer from one SACT run home to another. As a result the home did not carry out a detailed pre admission assessment and a social care assessment was not carried out. Instead a series of transition meetings were arranged. The manager from the previous home visited the home twice and the prospective resident also visited. The resident had a list of questions and time was spent giving responses to all their queries. All this information was documented. The resident was given a service user guide and placement agreement and a list of the house rules. The manager advised that they would be holding a mini-review in January. 56 St Saviours Road DS0000021338.V318675.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. 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. Care plans provide detailed information for staff on the action to be taken to meet the needs of the residents. If there are behavioural guidelines in place that have been written in response to an identified risk, reference should be made on the risk assessment to read the guidelines in place. EVIDENCE: Two care plans were examined on this occasion. Information provided was very detailed and there was clear advice on the action to be taken to meet each resident’s needs. In relation to one resident there were no goals identified, as they are still relatively new in the home. The manager advised that goals would be set following the resident’s next review. In the second care plan there was one goal identified. There were numerous risk assessments in place for both residents. In relation to one resident some of the risk assessments referred to the resident’s previous placement and it was not clear if they were still relevant in the new setting. Risk levels are not identified so it is not clear how often risks are likely to occur. Where it is assessed as 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 10 necessary behaviour guidelines are written to minimise the risk of accidents/incidents occurring. The home continues to use the TEACCH system to aid communication. One of the residents uses widgets, another uses a diary and a routine sheet and the third has a shift plan and weekly timetable. Residents are supported to make choices and decisions on a daily basis. This includes the activities they participate in and the food they eat. Rights versus risks are carefully considered. In relation to one resident there are guidelines in place to ensure their safety at all times and agreements have been reached in relation to travel, safety and contact with people. As the guidelines restrict this resident’s rights, in the interest of their safety it is recommended that this be fully discussed as a multi-disciplinary issue. 56 St Saviours Road DS0000021338.V318675.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. 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’ activity programmes afford regular opportunities for personal development, leisure and use of the community. The home is to be commended for the work carried out in assessing one of the resident’s cultural needs. EVIDENCE: In relation to one resident a staff member has carried out extensive research into their cultural and religious festivals and observances and this has been discussed with the resident’s relatives to check for accuracy. The manager advised that as a result of the research the staff team and the resident have a greater understanding of the subject and this has been of benefit to the resident and their family. 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 12 One of the residents has recently moved to the home and is gradually becoming more independent and confident with their routines and increased independence. During the inspection this resident did some ironing for the first time. Occasional prompts were given along with lots of praise and encouragement. This resident works two days a week and attends the Trust’s day centre for the remainder of the week. Another of the residents attends the day centre five days a week and a third resident has a varied timetable, some days at the day centre and some days accessing community facilities. Activities that the residents participate in include, cake making, jewellery making, ICT graphics, swimming, bowling and cinema. One of the residents has indicated a desire to do salsa dancing so the manager will make arrangements for this to happen in the New Year. One of the residents attends an evening club once a week. There are occasional trips to the local pub and residents enjoy both entertaining friends at their home or visiting friends elsewhere. One of the residents stated that they had all recently attended a lovely Christmas party, which had been organised by the Trust for all service users from the various homes and the staff teams. Staff support the residents to keep in contact with their relatives on a regular basis. Two of the residents receive very regular visits from their relatives. The third resident is in contact with their relative regularly by telephone. All of the residents have an annual holiday. One of the residents currently writes a shopping list of the food items required and staff then shop for the items. They cook their own meals independently and choose to eat their meals in their bedroom. However, this resident advised that everyone eats together once a week. The manager advised that a future goal for this individual would be to actually shop for their own food on a weekly basis. Menus seen in relation to the food served in the home showed that residents receive varied and well balanced diets. 56 St Saviours Road DS0000021338.V318675.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. 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. There are good measures in place to ensure that the healthcare needs of the residents are met. Good progress has been made in the involvement of the relatives of the residents in relation to the subject of dying and death. EVIDENCE: Records show that residents are supported to attend healthcare appointments as necessary to meet their individual needs. Residents are supported to attend options and dentists. One resident receives six weekly chiropody appointments and the other two residents are self-caring in this area. At the time of inspection, other that one inhaler and some homely remedies there was no other prescribed medication in the home. There are suitable storage facilities in the home should the need arise to store medication. Staff have not had training this year on medication but the manager advised that arrangements would be made for staff to receive training next year. The home has introduced a homely remedies policy. 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 14 The home has started the process of assessing the wishes/needs of residents in relation to dying and death. In relation to one resident it is not considered appropriate at this particular point to carry out the assessment yet. In relation to the other two residents the home has discussed the subject with relatives of the residents to see if there are any particular arrangements that need to be in place in the event of an unexpected death. The manager advised that she intends to carry on with the assessment to see further information from relatives. 56 St Saviours Road DS0000021338.V318675.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. 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. The home continually checks with the residents that they are happy with the care and support they receive. There are clear and detailed arrangements in place to ensure the safe management of at residents’ finances. EVIDENCE: There were no formal complaints recorded. There is a detailed complaint procedure in place. On a weekly basis staff ask residents using a pictorial format how they are feeling and if they are happy. Occasionally the residents raise issues that they would not be able to express verbally. An example of this is that one resident wrote ‘I like cycling but I hate art, it’s boring’. All of the staff team have received training on adult protection and prevention of abuse. There has been one adult protection alert raised by the home. The alert was reported to Social Services and the home are awaiting information on how the allegation is to be investigated. Records were seen in relation to the management of residents’ finances. In relation to DLA (Disability Living Allowance) there are different arrangements in place for each of the residents. DLA is paid into each of the residents’ bank accounts. In relation to two of the residents half of their allowance is paid to the Trust to pay for the use of the house car. In relation to the third resident, all the allowance is retained by the resident and is used for their monthly transport costs. As required at the last inspection the manager confirmed that 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 16 the arrangements for the management of DLA payments have been clarified with each of the residents’ relatives and placement authorities. In addition to the DLA, residents also receive their personal allowance, a recreation budget and a clothing allowance. The recreation budget is used to cover the cost of the annual holidays. During the inspection one of the residents was observed sorting out their budget allowance for the day. This is one of their individual goals and they stated that they are becoming more confident at the task and enjoy being more independent in this area. 56 St Saviours Road DS0000021338.V318675.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The property is homely and there is a continual programme in place to ensure that it is maintained well. Following the recent fire risk assessment the home needs to put in place an action plan showing how they have addressed the recommendations made. EVIDENCE: The property is well maintained. Pictures and ornaments displayed in the lounge and dining room have all been designed and made by the residents. In addition to the main lounge there is a dining room and a small conservatory. The conservatory continues to be used as a relaxation room and there is a swing chair and specialist lighting. On the first floor there is a small room, which is used by one of the residents as a music room. The manager reported that the bathroom would be redecorated and a new bathroom suite would be fitted in the New Year. In addition the hallway will be painted. The residents have had input into the choice of colour scheme. One of the residents who is a recent admission to the home showed the inspector 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 18 to their room. They advised that they had chosen the colour scheme for their bedroom and were happy with the outcome. They are also going to choose new furniture for their bedroom in the coming weeks. Each of the residents has a house day one day a week and on this day they clean and tidy their bedroom. Staff support residents in this task as needed. As required at the last inspection of the home the flooring in the kitchen has been replaced. All areas of the home seen during the inspection were clean and there were no unpleasant odours. A fire risk assessment has been carried out in relation to the building. As a result new fire doors have been fitted in many areas in the home and selfclosing devices have been fitted to the lounge, dining room and kitchen doors. The home has yet to put in place an action plan detailing the action taken in response to the recommendations made. Where a decision has been taken not to comply with the recommendations made this needs to be discussed and agreed with the Responsible Individual for the home. Records showed that regular tests are carried out to monitor fire alarms. 56 St Saviours Road DS0000021338.V318675.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Staff are well supported and receive regular opportunities to attend training to update their knowledge and skills. EVIDENCE: The rota provided shows that staffing levels are appropriate to meet the needs of the residents. Each staff member is allocated a minimum of six training days each year. The manager advised that all the staff team are up to date with mandatory training. No new staff have been appointed since the last inspection of the home. There is still one full time vacancy. The manager advised that this has been left vacant so that they can use regular relief staff on a regular basis. Having this in place means that they can be more creative with the activities programme and activities can be arranged more spontaneously. One staff file was examined and it was ordered and contained all information required by the Regulations. There was evidence that the staff member had received regular supervision. A staff member spoken with stated that they receive regular supervision and also that the manager is available outside of supervision times. One of the care staff is currently working towards NVQ level 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 20 three. On successful completion of this course another staff member will then commence studying for the course. 56 St Saviours Road DS0000021338.V318675.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): Quality in this outcome area is (excellent) This judgement has been made using available evidence including a visit to this service. The home is well run, staff are clear about what is expected of them and residents are given clear and consistent advice about the structure of their day. There are very good measures in place to seek the views of residents and their relatives on the quality of the care provided. EVIDENCE: The manager is currently working towards NVQ level four and the Registered Manager’s Award. A staff member spoken with stated that their work is ‘immensely rewarding’. They described the manager as ‘very supportive’ and stated that they deal with all issues as they arise. There is a communication book in place and in addition there is a diary and handover sheets. As often staff work alone it is essential that there is clear communication in place. Staff spoken with stated that communication is one of the home’s strong points. Staff meetings are also held on a weekly basis. 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 22 In relation to quality assurance the home distributes satisfaction questionnaires to residents and to their relatives on an annual basis. A partnership day is then organised and everyone is invited to attend. During this event everyone is given feedback on the outcome of the questionnaires. Plans for the coming year are also discussed. In addition to the partnership days an independent visitor visits the home on an annual basis and writes a report of their findings. The visitor might be a director of the Trust but would have no general contact with the home on a regular basis. The Trust has Investors in People status and in addition has accreditation to the National Autistic Society. As part of the inspection process, prior to the inspection, comment cards were sent to the home for distribution to the residents. One of the residents appeared not to understand the questions, a second was able to answer some of the questions and when a staff member explained in more detail was able to give a positive response. A third resident responded very positively to all questions and commented ‘I am happier living at St Saviours than where I was before it is near town so I can be more independent and quiet at night so that I can get a good rest’. Following the inspection attempts were made to contact the relatives of the residents to seek their views on the quality of the care provided in the home. One relative was spoken with and they stated that they are `100 happy with the care’. They welcome the opportunities provided by the home to meet with the staff team and the parents of the other residents. Since the last inspection the Trust has completed the revision of the policies and procedures manual. The manager advised that she is now ensuring that staff read through and discuss policies on a regular basis and that when this is achieved staff sign that they have read and understood the documents. In relation to health and safety, records showed that hot water temperature readings are taken and recorded on a weekly basis. 56 St Saviours Road DS0000021338.V318675.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 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 4 4 X X 3 X 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 24 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 YA9 Regulation 13(4) Requirement The home must revise the risk assessments in place in relation to one resident to ensure that they are all relevant in the new care setting. Where a resident’s rights are restricted in the interest of their safety any guidelines in place must be agreed with a multidisciplinary team. An action plan must be drawn up detailing the action taken in response to the recommendations made following the recent fire risk assessment. Where a decision is made not to comply with some of the recommendations made this must be discussed and agreed with the Responsible Individual for the home. Timescale for action 31/01/07 2. YA9 13(b,c) 15/02/07 3. YA24 23(4a) 31/01/07 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA2 Good Practice Recommendations The manager should carry out full pre admission assessments for all residents admitted to the home whether they are being transferred from within the company or admitted from outside of the organisation. Where there are guidelines in place that link in with a particular risk assessment it should be made clear on the risk assessment to refer to the guidelines. 2. YA9 56 St Saviours Road DS0000021338.V318675.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 56 St Saviours Road DS0000021338.V318675.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. 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