Inspection on 27/03/07 for 66 St Edmunds Road

This inspection was carried out on 27th March 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

66 St Edmunds Road 07/11/07

66 St Edmunds Road 28/11/05

66 St Edmunds Road 20/06/05

66 St Edmunds Road 01/03/05

66 St Edmunds Road 25/08/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 66 St Edmunds Road Stowmarket Suffolk IP14 1NU Lead Inspector Mrs Sharon Lacey Unannounced Inspection 27th March 2007 10:30 66 St Edmunds Road DS0000037220.V334688.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 66 St Edmunds Road DS0000037220.V334688.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. 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 66 St Edmunds Road Address Stowmarket Suffolk IP14 1NU 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) 01449 626210 Suffolk County Council Post Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2005 Brief Description of the Service: 66 St. Edmunds Road is a registered care home for five adults with learning disabilities, owned and administered by Suffolk County Council. It is situated in a residential area of Stowmarket and within easy reach of local amenities and resources. The accommodation is single storey and comprises of five single bedrooms, communal lounge and dining facilities, two communal bathrooms and one shower room. There is limited parking to the front of the building. 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 66 St Edmunds Road is a five-bedded residential resource for adults with learning disabilities owned and administered by Suffolk County Council and sited in a residential area of Stowmarket. This was a routine Unannounced Inspection, which took place over six and a half hours. This was a Key Inspection covering twenty-nine of the National Minimum Standards. A tour of the home was completed and also an inspection of relevant records and documentation took place. Areas looked at included information given to residents before being admitted to 66 St Edmunds Road; information gained when residents first come into the home; how information is given to staff on the care required; the facilities and environment of the home; and any complaints that may have been received since the last inspection. Also staffing and management of the home were inspected. Due to the limited communication abilities of residents it was difficult to gain detailed feedback on the quality of services provided, although all residents appeared very happy and relaxed in the homely environment. Staff were observed during the day interacting with residents. Questionnaires were sent out to relatives and residents regarding their experiences of the home, but only one has been returned. At the end of the day the Inspection was discussed with the Acting Manager and advice and guidance was given regarding the findings. What the service does well: What has improved since the last inspection? The home has continued to progress under the guidance of the acting manager. Changes have been made to the working practices and administration of the home. Staff have worked hard to ensure that all residents have been provided with a detailed plan of care which places a strong emphasis on the way in which they wish their care to be delivered. 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 6 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. 66 St Edmunds Road DS0000037220.V334688.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 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. Quality in this outcome area is good. Information is provided to prospective residents to enable them to make a decision about the home, but this needs to be reviewed and updated. Residents can expect to receive a detailed assessment of their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s Statement of Purpose and Service User Guide was available in the home’s hallway. Both documents contained all the information required by Regulations 4 and 5 of the Care Homes Regulations 2001. Both documents were well presented and set out the services that the home seeks to provide; although the Acting Manager stated they had not been reviewed since the last inspection and some information was at present out of date. A copy of the home’s inspection report and Registration certificate were also available. The home has a clear admissions procedure and this is also part of the home’s Statement of Purpose. An admission assessment is completed to identify the individual needs of prospective residents and includes the areas listed in Standard 2.3 of the National Minimum Standards. When completed this document should provide a clear outline as to whether a prospective resident’s needs could be met at the home. The home has a ‘service agreement’ with each resident, but it was noted that this did not include details of the room to be occupied. 66 St Edmunds Road DS0000037220.V334688.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): 6, 7 and 9. Quality in this outcome area is excellent. Residents residing at the home can expect to be provided with and involved in the production of a detailed plan of care, which reflects their individual care needs, goals and aspirations. Residents can also expect to be supported to take informed risks as part of their daily life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All documentation required was available and easy to ready. Resident care plans have now been developed and clearly determine the assessed needs of the individual residents. The care plan is updated on a yearly basis and is drawn up with the involvement of the resident and also other family members. It is a comprehensive form, which includes individual’s likes, dislikes and chosen routines. A separate form for ‘Social Life Skills’ is completed on a yearly basis and provides clear information on how much assistance each resident requires and highlights where the individual may have improved or deteriorated in their daily life skills. All residents’ documents were presented in well-organised and user-friendly format. 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 10 Clear detailed risk assessments were available and included health and well being, outside activities and moving and handling. The assessments identified the risk, how this could be reduced and the staffing ratio required for each risk. The home was able to evidence that resident care plans were reviewed on a regular basis. A review is completed each month and this is then incorporated in to the individual’s yearly review, where other external agencies such as day services and social services would be required to have an input. Most present residents have relatives, but advocacy services can also be arranged if required. None of the present residents mange their own finances, but the home has clear systems in place to assist with this. 66 St Edmunds Road DS0000037220.V334688.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): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. Residents living at the home can expect to be provided with a range of leisure activities and occupational/educational opportunities. Residents can also expect to be provided with a planned menu of meals. The residents also have their rights and freedom of choice and movement recognised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home are in the process of introducing a ‘pilot scheme’ were each resident can choose to stay at home and do chosen activities rather than go to the local day centre. This is only in its first month, but the Acting Manager is confidant that residents will have more choice over their daily tasks and outside activities. Due to the pilot routines within the home are more relaxed and residents are able to participate in activities they would like to do. On the day of the inspection two residents went into town to get personal shopping and also food for tea. 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 12 There was clear evidence that all five residents living at the home are provided with a range of activities and community contact. Community links are still being developed and the Acting Manager and staff have tried to include local neighbours in themed events at the home. Monthly events have been organised and include a BBQ, a disco evening, a meals out with Fireworks and a Christmas party etc. Individual residents had also been to a ballet, horse riding and swimming. On the day of the inspection the home had only two members of staff and four residents. It was considered that as some residents required a ratio of two staff to one on outside activities, which would restrict resident’s choice and also have an impact on their new project. The home has a planned 4-week menu of meals for residents. These menus suggested that residents are provided with a varied and nutritious diet. Menus seen showed that there was a main choice each day and either ham or cheese salad as an alternative. One relative reported that ‘that she had requested the home to support her daughter in healthy eating’ – but added she had to often remind them of this. Observations during the inspection evidenced that residents have unrestricted access throughout the building and are well integrated into the daily routines. Staff were noted to interact well with residents. Staff support residents to maintain family links and the home has an ‘open’ visiting policy. 66 St Edmunds Road DS0000037220.V334688.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): 18, 19 and 20. Quality in this outcome area is good. Residents can expect to receive personal support in the way they prefer and to have their physical and emotional care needs monitored and met. The home has clear procedures on the safekeeping and administration of medication, but this had not been fully adhered to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident care plans evidenced that each service user is provided with an Essential Life Plan, which sets out a “pen picture” of levels of support required, including those around personal care. This plan highlights how individual residents would like to have their personal care support provided and also includes likes, dislikes and preferred routines. The home has clear guidance on medication and intrusive medication. Staff had received intrusive medication training from the local community nurses and files contained training certificates to confirm staff were competent. Staff receive medication training at induction and also via Suffolk County Council. When looking at the medication records it was noted that some gaps were present. On further investigation it was noted that these had been left blank on the days residents were on ‘social leave’; this was brought to the Assistant 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 14 managers attention. The home was also able to evidence that staff had undertaken training on Epilepsy. The home was able to evidence that the physical and emotional needs of residents are monitored and they have access community health facilities where required. One section of the service user care plan is devoted to the health care needs of the individual and details how these are to be met. A log of all hospital, GP or dental visits is also maintained. The home is able to access learning disability assessment and treatment services for each resident via GP referral. 66 St Edmunds Road DS0000037220.V334688.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): 22 and 23. Quality in this outcome area is good. Residents and their families can expect to be provided with sufficient information to enable them to make a complaint about the service. Residents can also expect that the home’s policies and procedures protect them from abuse, neglect and self-harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear and robust complaints procedure, which is available to all residents and their families. This is also part of the Service Users Guide and a copy of this document is provided to all residents and their families. An additional copy is displayed on the home’s notice board, making it accessible to any visitors to the premises. The home has also recently introduced a Complaint/Compliments folder, which allows visitors and residents of the home to record any concerns or compliments they may have about the service. Since the previous inspection, no complaints had been received. At the time of the inspection, the home was able to evidence that all of the staff had completed training programme on the Protection of Vulnerable Adults. The home was also able to evidence that it had a copy of and adhered to the local Protection of Vulnerable Adults Procedure, which is produced jointly by health and social services. The home had clear policies and procedures regarding resident’s money and financial affairs. One resident’s money was checked on the day of the inspection and found to be in order. Suffolk County Council also completes financial Audits on the home. 66 St Edmunds Road DS0000037220.V334688.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 and 30. Quality in this outcome area is good. Residents are provided with accommodation, which is comfortable, homely and clean. Residents have access to both private and communal accommodation, which meets their needs and lifestyle. The home has sufficient bathroom facilities; but residents are not provided with bedroom accommodation, which is equipped with basic fixtures such as wash hand -basins. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 66 St Edmunds Road comprises of a single storey dwelling, which is sited in a residential area of Stowmarket and blends well with the surrounding domestic dwellings. The home has five bedrooms, all for single occupancy and a good provision of communal accommodation, which includes a spacious and comfortable lounge and a well-equipped kitchen and dining room. New dining room furniture had just been bought and was in the process of being put together. There is also a garden room, provided with wicker furniture, which leads out onto the pleasant and rear garden. Fencing had been erected to ensure the garden was secure 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 17 for residents, but on the day of the inspection it was noted that a fence panel had fallen down and gave access to a neighbours garden. The home has one office, which is also used as a “sleeping-in” room for one member of staff at night and there is also another ‘sleep-in room’ at the other end of the bungalow for the second member of staff. Resident bedrooms were comfortably furnished, attractively decorated and contained personal belongings and equipment purchased by residents. Bedrooms seen reflected the personal tastes and interests of the occupant. Although none of the resident bedrooms had the benefit of ensuite facilities, there were two communal bathrooms and a shower room. Resident’s bedrooms do not have wash hand basins, but risk assessments have been completed to support this decision. The home will need to ensure that when current residents have vacated each room, a wash hand basin is provided for any new resident. The home is well decorated and many of the rooms have had new carpets laid. The laundry room is in the process of being updated and is waiting for appropriate flooring. In general the home provides a good standard of accommodation for residents, both communal and private. All areas of the building were maintained to a good standard of decorative order and repair and were furnished appropriately. All areas were maintained to an acceptable standard of cleanliness and there were no unpleasant odours. During a tour of the home it was noted that personal care gloves were easily accessible to residents in the bathrooms, so it was suggested that these were removed and placed in a safe, but easily accessible place for staff. Residents looked happy and relaxed in their accommodation and residents were observed in the communal lounge, kitchen and bedrooms. 66 St Edmunds Road DS0000037220.V334688.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is good. Staffing should be at a ratio, which is sufficient to meet resident’s individual needs. Staff receive appropriate training and have the knowledge and skills to carry out their roles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear recruitment policy, which safeguards both staff and residents. Suffolk County Council completes most of the checks on staff, but the home are involved in interviews with new staff. Those residents who are able are also involved in the interview process through providing a tour of the home. One new staff files was inspected and this contained all the required information. It was also noted that this had been well laid out and presented which made it easy to find the required evidence. On the day of the inspection, two members of staff were supporting four residents within the home. Due to the level of support that was needed for some of the residents when participating in the community (two staff to one resident), the staffing levels at the home on the day of the inspection would not allow residents to pursue chosen activities. This would especially have an impact on the ‘project’, which had recently been implemented to allow more 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 19 choice for the residents in activities and community contact. A relative stated ‘she did not feel residents did enough – except for day services’. During the night period two support workers on a “sleeping in” basis staff the home. Staffing rotas seen at the time of the inspection stated that three staff should have been on duty, but one had gone sick. The home were also having some difficulties gaining sufficient staff to support the home the next day. During the inspection staff undertook their roles in a confident and professional manner and were clear about their responsibilities. Staff were observed interacting with residents in a professional but warm manner and it was evident that good working relationships existed. Staff had a clear understanding of the resident’s individual needs. Feedback from relative stated ‘The carers are very good’. Training records clearly evidenced that staff had attended appropriate training. Training included challenging behaviour, Protection of Vulnerable People, Person Centred Care, Manual Handling and intrusive medication. Suffolk County Council have recently changed their mandatory training and it was noted that first aid and food hygiene is now not on the list. Five of the staff members have achieved an NVQ Level 3 in care and two have NVQ 4. 66 St Edmunds Road DS0000037220.V334688.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. Quality in this outcome area is good. Residents can expect the home to be managed effectively and in their best interests. The home does not at present have any staff with first aid training. The home’s quality assurance system needs to be developed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mr. David Gilbert, who is also the registered manager for another residential learning disability resource within the same area, is currently managing the home. Whilst the Commission agreed that Mr. Gilbert could manage the home on a temporary basis without registration, this situation has existed since March 2005 and the need for his registration with the Commission is now under consideration. Since Mr. Gilbert has taken over the management of the home, there has been significant improvement in many areas of the service, such as the provision of clear and detailed care plans for each service user and the provision of a Statement of Purpose and Service User Guide as requested by regulation. An Acting Residential Resource Manager supports Mr Gilbert 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 21 and it is clear that the home is managed in an open and positive atmosphere, which benefits not only the staff but also the residents. The home has some quality assurance systems in place, but the acting manager is in the process of developing these further. Residents and relatives are approached for their views, but this needs to be developed to include other professionals who are involved with the home. The home does not produce a written quality assurance report at present. Regular Regulation 26 reports are completed on the premises. The home has policies and procedures to the health and safety and welfare of staff and residents. The acting manager is aware of his responsibilities regarding safeguarding both staff and residents. Regular checks on gas appliances, fire alarm system, water temperatures and electrics were seen and in order. An accident folder was viewed and in order. 66 St Edmunds Road DS0000037220.V334688.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 2 2 3 3 X 4 X 5 3 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 2 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 X X 2 X 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 23 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 YA1 Regulation 6 (a)(b) Requirement The Registered person shall keep under review and where appropriate revise the Statement of Purpose and Service Users Guide and notify the CSCI and service users of any such revision. Timescale for action 31/05/07 2. YA20 13 (2) The registered person shall make 31/05/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This in connection to ensuring staff complete the MAR sheets correctly and there are no gaps. 3. YA26 23(2)(j) The Registered Persons must ensure that all newly admitted residents are provided with a wash hand basin in their bedroom. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure DS0000037220.V334688.R01.S.doc 31/05/07 4. YA33 18 (1)(a) 27/03/07 66 St Edmunds Road Version 5.2 Page 24 that at all time suitably qualified, competent and experience persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. This is in connection to ensuring there are sufficient staff in the home to assist the residents to participate in daily living skills and community activities – which is in line with the present ‘project’ being run at the home. 5. YA39 24 (1)(a)(b) (2) The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of the care provided at the care home. The registered person shall supply to the Commission a report in respect of any review conducted by him for the purposes of paragraph (1), and make a copy of the report available to service users. The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; and shall make suitable arrangements for the training of staff in first aid. 30/06/07 6. YA42 13 (a)(c) 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 25 No. 1 2. 3. Refer to Standard YA5 YA12 YA20 Good Practice Recommendations Recommend you add detail of the room to be occupied to the home’s Service Agreement. Ensure sufficient staff are always at the home to enable residents to participate in chosen and organised activities. Recommend written consent is gained from residents regarding assistance with their medication and this clearly recorded on their individual file. Recommend a PRN form is introduced which clearly describes when staff should administer this medication. Ensure the garden is secure to safeguard residents. Recommend a ‘safer system’ be introduced for the storage of personal care gloves. 4. 5. 6. YA20 YA29 YA30 66 St Edmunds Road DS0000037220.V334688.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 66 St Edmunds Road DS0000037220.V334688.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!