Inspection on 19/07/05 for 7 Eworth Close

This inspection was carried out on 19th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

7 Eworth Close 03/09/09

7 Eworth Close 24/07/07

7 Eworth Close 24/07/06

7 Eworth Close 01/11/05

7 Eworth Close 22/09/04

7 Eworth Close 16/03/04

7 Eworth Close 03/11/03

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Eworth Close (7) 7 Eworth Close Grange Park Swindon Wiltshire SN5 6BT Lead Inspector Bernard McDonald Unannounced 19 & 22 July 2005 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 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 Stationary 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. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Eworth Close (7) Address 7 Eworth Close Grange Park Swindon Wiltshire SN5 6BT 01793 878169 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ian Charles Mrs Maria Arthur Care Home 5 Category(ies) of LD Learning disability registration, with number of places Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8 March 2005 Brief Description of the Service: 7 Eworth Close is a modern two storey house with a large garden. The home offers care and accommodation to both men and women who have a learning disability. The service replicates principles of ordinary living and strives to provide services that take account of ‘social role valorisation’ i.e. principles of choice, dignity, respect and community presence. Each service user has their own bedroom and share communal areas. The service is designed for people that can manage stairs and want to live with others. Any behaviour’s must be manageable within a small domestic environment. The home, which is located in the Grange Park area of Swindon, is a partnership that trades as Ian Charles. They have a one other similar care home nearby. There is a full-time manager and a small staff team. Typically there is one person on duty throughout the day with an additional member of staff on duty between 10.30am and 8.00pm. At night time the staff take it in turns to sleep at the home and to be available to assist with any night time needs or emergencies as they arise. Service users are expected to engage in day activities during the week. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over two days. The first day of the inspection was unannounced. The inspector returned to the home three days later by arrangement with the manager. The inspector met with four of the five service users over the two days and was able to meet in private with three of the service users to obtain their views on the service they receive. The inspector viewed all areas of the home and met with three support staff. The inspector found there were a number of requirements outstanding from previous inspection reports. Two requirements have been outstanding over two inspections and the Commission will be taking further enforcement action with regard to these requirements. An ‘escalated warning’ letter will also be sent to the provider regarding a further requirement that is outstanding from the previous inspection. What the service does well: What has improved since the last inspection? There has been improvement in ensuring service users are involved in their care review and the reviews are more focussed on outcomes. This shift in focus has been of benefit for service users in promoting their independence. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 6 The format for recording care reviews has changed and is more focussed on the aspirations and goals of service users. Two service users confirmed they had recently attended their review meeting. The improvements in the staffing levels has also brought benefits to service users. Staff now have more opportunity to go out with service users on an individual basis and support them in their chosen activity. 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. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 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 standard(s) 2, 3, 5. The home can demonstrate how service users aspirations and needs are being met. The home is still failing to ensure service users are provided with a standard form of contract. EVIDENCE: There have been no new admissions to the home since the last inspection. Discussion with the manager demonstrated a good understanding of the procedures for admitting service users to the home including providing opportunities to meet with staff and service users living at the home prior to moving in. Following a requirement made at the last inspection the home has reviewed the support needs of service users. Discussion with service users confirmed they had attended their recent review. The new format for the review process now focuses on how service users aspirations and goals are being considered to maximise their independence. A copy of the contract was held in the service user guide. These documents did not fully reflect the full cost of care being provided. The contracts had not been signed and did not show that they had been discussed with the service users. It has been a requirement at the last two inspections that a standard form of contract be developed for the provision of services and facilities between the Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 9 registered provider to service users. This requirement has not been met and the registered provider must provide a copy of the contract to the Commission to ensure compliance and avoid any further action being taken. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9. The home is involving service users in their care reviews and can demonstrate how their needs are being safely met. EVIDENCE: The inspector examined all service users care plans and found they had all been reviewed in the past six months. Care plans had been significantly improved to focus more on the aspirations goals of service users and ways to maximise their independence. Service users did say they had been involved in their care plan meeting. The manager confirmed she wants to further improve the care plans by focussing more on outcomes for service users. Discussions with staff showed an understanding of the needs of service users and improvements in enabling service users to make their own decisions about their lives. This practice is also reflected in the care plan where service users rights and decisions to choose whether they wish to participate in activities are clearly recorded. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 11 Discussion with service users confirmed they are able to choose the time for getting up and going to bed and this practice was reflected in service users daily notes. Two service users stated they were happy at the home, one service user stated they were looking at commencing a new college course after the summer break. Another service user stated they had picked a number of courses they wanted to look at before deciding which one to choose. To further promote service users choice and rights, information on local advocacy service should be made available in the home. Risk assessments have been completed and were held on service users files. Risk assessments examined had all been reviewed in the past year. As a matter of good practice and to further ensure all staff are aware of any risks to service users, staff should sign to demonstrate they had read and understood the completed risk assessment. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 17. The home is ensuring service users can participate in meaningful daytime activities. The failure of the home to develop a policy on holidays is having an impact on service users rights, choice and opportunity to sample new experiences. The menu reflects service users likes, dislikes and individual tastes. EVIDENCE: Discussion with two service users confirmed they were happy with their daytime activities. One service user confirmed they were involved in work experience but did not want any extra days or to pursue the option of paid employment. Service users daily notes demonstrate opportunities are provided for trips out to the cinema, meals out and trips to the pub. There is public transport to Swindon centre every twenty minutes and the bus stop is close by. Two service users do access this service without the support of staff. Service users are encouraged to pursue hobbies and interests and one service user confirmed they were looking at enrolling on a cookery course at college as they enjoyed cooking. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 13 The manager confirmed since the increase in staff, service users now have more opportunity to go out on an individual basis or in a small group. A requirement was made at the last inspection that the registered person must review and update the policy on holiday provision. The manager stated this requirement has not been met. The manager stated that service users have not had a holiday for over eighteen months due to no decision being made over who pays for holidays. Two service users have asked to go on holiday this year and staff are willing to support them. The Commission will be pursuing this matter with the registered provider. One service user is supported to maintain regular contact with their family mainly through telephone calls. Discussion with one service user confirmed staff were helping to develop a life storybook, which was kindly shown to the inspector. The service user stated they wanted to make contact with a close relative and staff were helping to initiate contact. The manager confirmed that menus are planned in consultation with service users at house meetings. One service user confirmed they were able to help prepare and cook meals. The main meal of the day is in the evening and service users are encouraged to eat their meal together in the dining area. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20. The health care needs of service users are being met. EVIDENCE: Service users records demonstrate health care appointments are being made. Recent appointments include visits to the dentist the optician and the chiropodist. A record of the appointment included the reason for the visit and any specialist input or treatment required. The health needs of one service user have been of concern to staff at the home; specialist appointments, visits to the hospital and frequent visit to the GP have all been supported by staff at the home. Health action plans are slowly being worked through by staff. Following a requirement made at the last inspection the home has reviewed the decision regarding the ability of one service user to self medicate. A risk assessment has been completed and following the care review it has been agreed the service user would work towards becoming more independent in administering their medication. Examination of medication records demonstrate the home was accurately recording all medication administered to service users. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 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 standard(s) 22, 23. The home is ensuring service users views are listened to and protection from abuse is a priority for staff. EVIDENCE: Discussion with the manager confirmed the home has received no complaints since the last inspection. The complaints procedure was available in the home and specified any complaint would be responded to within twenty days. Discussion with one service user confirmed they had no complaints about the care at the home. Discussion with one member of staff demonstrated an awareness of what constitutes abuse. The staff member was very clear that they would report any concerns regarding the welfare of service users. A second member of staff confirmed they had received a copy of Swindon and Wiltshire’s “no secrets” guidance for staff but had not received any abuse awareness training. It is recommended that all staff receive this training. Policies and procedures are in place for managing aggression towards staff. The home was holding money on behalf of all service users. Examination of the records demonstrated service users money was being accurately recorded. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 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 standard(s) 24, 25, 26, 27, 28, 29, 30. The home was clean, tidy and provided sufficient personal and communal space for everyone living in the home, however deficits in the décor and furnishings in one service users bedroom need to be addressed. EVIDENCE: The home is situated in a quiet residential area in the grange Park area of Swindon. Service users accommodation is on two floors. There are two single bedrooms on the ground floor and three single bedrooms on the first floor. A staff sleeping in room is also on the first floor. The inspector viewed all areas of the home. One service user stated they liked their bedroom and had everything they needed and confirmed that the crack window pane had been replaced. One service users bedroom had a chest of drawers with some of the handles missing and it is a requirement that these draws are either repaired or replaced. The wallpaper in the bedroom was coming away from the wall and it is recommended this be stuck back down. Another service users bedroom was going to be decorated over the coming week. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 17 The lounge had been decorated since the last inspection and one service user stated they had helped to choose the colour. The bathing facilities are situated on the first floor and comprise of a bath with toilet and a separate shower room and toilet. This enables service users to have a choice of bath or shower. In addition there is a separate toilet on the ground floor close to service users communal lounge. Service users have access to all areas of the home and there is a safe and secure rear garden that is used by service users and for Bar B Q’s at weekends. The laundry is situated in the garage and comprises of two domestic style washers and a tumble dryer. Two service users confirmed they have responsibility for their own laundry Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35 Progress is being made to ensure service users are supported by a trained workforce. The home is failing to ensure the protection of service users due to poor recruitment practices. EVIDENCE: There have been improvements to the numbers of staff on duty following a requirement made at the last inspection. Examination of the rota demonstrated one member of staff on duty between 10.30am and 10.30pm and a further member of staff working between 8am and 8pm. The manager confirmed the home still has staff vacancies for two part time staff, however the exisisting staff team is currently covering these hours. The increase in the number of staff hours provided at the home is proving beneficial to service users. Staff confirmed they are now able to take service users out on an individual basis or in very small groups instead of everyone having to out together. Discussions with two members of staff demonstrated a good awareness of the needs of service users and a confidence in their ability to meet their needs. Discussion with two service users confirmed they “liked the staff” and that they were “very good”. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 19 Discussion with the manager confirmed the majority of staff are working towards completing NVQ training. One member of staff hopes to complete NVQ 3 next year and one member of staff should complete NVQ 2 in August. One member of staff has completed a five- day learning disability module course and a person centred planning workshop. The manager confirmed that all staff have now been put forward for these courses. While this has been an improvement on the last inspection the manager needs to ensure all staff receive training in the principles and practice of care. The manager advised that as part of her role she is going to develop training pathways for all staff. Three staff recruitment records were examined. One of the records examined showed three references had been applied for and only one had been received. Gaps in the member of staff employment history had not been explored. A CRB from the member of staff previous employer was available but no record of a CRB check having been taken by the home prior to taking up their employment. The manager stated she was not aware that CRB’s were no longer transferable. The manager was advised that the member of staff could no longer work in the home unsupervised until a satisfactory CRB had been received at enhanced level. The manager was further advised to immediately apply for a POVA first check. There were further discrepancies in the recruitment records of other staff employed at the home relating to gaps in employment records and photographs of staff members. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 42 The manager needs to ensure she has the necessary qualifications to ensure service users can benefit from a well run home. The home is failing to ensure there is an effective quality monitoring system in place that seeks the views of service users. The home is failing to ensure the safety of service users due to the safety of electrical equipment not being checked. EVIDENCE: The manager confirmed she has now completed her application to complete NVQ 4 in management and care. The manager stated the application would be submitted by 8/08/05. The manager has been in post since 1999 and has extensive experience of working with people with learning disabilities. It has been a requirement at the last two inspections that action must be taken to ensure a quality assurance system is put in to place which includes the views of service users their supporters and stakeholders. The Commission is now taking enforcement action regarding this issue. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 21 The Commission has received copies of the reports made following the visits by the registered provider as required by regulation 26 of the Care Homes Regulations 2002. The quality of the reports is poor and does not give any insight into the service or what it is like for service users living at the home. Examination of the fire logbook demonstrated the home was ensuring fire safety requirements were being met at the home. Discussion with two service users confirmed they were aware of what to do in the event of the fire alarm sounding. The fire record book demonstrates fire safety checks were being completed and the last recorded fire practice was held on 15/6/05. To ensure the safety of service users it has been a requirement at two previous inspections that Portable Appliance Testing (PAT) is completed at the home. The manager stated the registered provider has instructed her to complete these electrical tests but she is not confident in her ability to complete the task safely. This attitude is a concern to the Commission as it could compromise the safety of service users and enforcement action will now be taken. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x 1 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 1 3 x 3 Standard No 31 32 33 34 35 36 Score x 2 3 x 1 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Eworth Close (7) Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 1 x x 1 x DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 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 5 Regulation 31(1) CSA Requirement The registered person must supply the CSCI with a copy of a standard form of contract for the provision of services and facilities by the registered provider to service users. The registered person must review its policy on holiday provision for service users, clarifying what consents are needed, who pays for what, safe levels of staffing and the staffs responsibility and obligations on such holidays. This requirement is outstanding from the previous inspection and an escalated warning letter is being sent. The registered person must either repair or replace the chest of drawers in one service users bedroom. The registered person must ensure no staff are employed to work at the home unless the home has first received a satisfactory CRB at enhanced level / POVA 1st check as part of Timescale for action 01/10/05 2. 14 12(a)(b) (2)(3) 01/11/05 3. 26 23(2)(b) (c) 19(1)(a) (b)(i) 01/10/05 4. 35 01/08/05 Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 24 their pre employment checks. 5. 35 The registered person must 01/08/05 ensure all documents specified in Schedule 2 of the Care Homes Regulations 2001 are received on each member of staff prior to them commencing employment at the home. 9(1)(2)(b) The registered manager must 01/09/05 (i) apply to enrol on the registered managers award and NVQ 4 in care. 24(1) The registered person must take 01/11/05 action to ensure there is a robust quality assurance system, which informs service users, staff, the manager and directors as to the quality of the service provided. It must also identify areas for improvement and detail its findings. This requirement is outstanding from the last two previous inspection reports and the Commission will be taking further enforcement action. The registered person must ensure that portable appliance testing is carried out by a person who has the relevant knowledge and skills and is competant to carry out the test. This requirement is outstanding from the last two previous inspection reports and the Commission will be taking further enforcement action. 19(1)(b) 6. 37 7. 39 8. 42 13(4)(a) 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 25 Eworth Close (7) 1. 2. 3. 4. 5. Standard 7 9 27 33 23 The registered person should ensure that information on local advocacy services is made available to service users. The registered person should ensure staff sign risk assessments to demonstrate they have read and fully understand the risk to service users. The registered person should repair the wallpaper in one service users bedroom. The registered person should develop a training plan for each member of staff. The registered person should ensure all staff receive training in the protection of vulnerable adults. Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 Page 26 Commission for Social Care Inspection Suite C, Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB 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 Eworth Close (7) DD51_D01_S3195_EWORTHCLOSE7_V234976_190705_STAGE4.doc Version 1.30 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!