Inspection on 25/08/05 for 72-74 Walsingham Road

This inspection was carried out on 25th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

72-74 Walsingham Road 24/08/06

72-74 Walsingham Road 10/02/06

72-74 Walsingham Road 05/01/05

72-74 Walsingham Road 06/07/04

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Southfields

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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 72 - 74 Walsingham Road 72 - 74 Walsingham Road Hove East Sussex BN3 4FF Lead Inspector Jennie Williams Announced 25 August 2005 09:30 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. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 72 -74 Walsingham Road Address 72 - 74 Walsingham Road Hove East Sussex BN3 4FF 01273 888077 01273 732044 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) Care Management Group Mrs Sandra Elizabeth Stinton Care Home 12 Category(ies) of Learning disability (LD) 12 registration, with number of places 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 That the home is registered to accommodate up to twelve (12) service users. 2 Service users should be aged between twenty-five (25) and sixty-five (65) years upon their admission. 3 That the category of service users admitted have a learning disability, not falling within any other category. Date of last inspection 5 January 2005 Brief Description of the Service: 72-74 Walsingham Road is one of many homes within the Care Management Group (CMG). This home was taken over by CMG in November 2002. It is registered to provide accommodatoin for twelve residents, between the ages of twenty-five (25) and sixty-five (65) years on admission with a learning disability. The home is located in a quiet residential area in Hove. The establishment is two homes that have been joined together. There is access to local amenities and public transport. The home has access to a mini bus. There is no parking available at the home, but free parking is available in the adjacent streets. There is one double room. All other rooms are for single occupancy and are located over two floors. The twelfth room is located on the second floor but is not currently in use. Residents must be able to independently mobilise to access the first and second floor. The layout of the home is not suitable to accommodate wheelchair users. The home has access to a mini bus. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 72-74 Walsingham Road will be referred to as ‘residents’. This report is based on the findings of the specified inspection date. This announced inspection took place over six hours on the 25 August 2005. Staff files, some policies and procedures, records, care plans, individuals’ personal allowance and medication procedures were inspected. A tour of the home was provided. The environment and some individual rooms were spotchecked. The Inspector ate lunch with some of the residents. Staff and residents were spoken with throughout the inspection process. The pre inspection questionnaire was sampled and the Inspector received comment cards from two residents, three visiting health professionals and four relatives/visitors. There were eleven residents present on the day of the inspection. There were six residents taken out for lunch and the afternoon. The Inspector would like to thank staff and residents for their assistance throughout the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 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 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 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 & 4 The home has information available to prospective residents and their representatives to make an informed decision if the home is suitable for their needs. All prospective residents are assessed prior to moving into the home. EVIDENCE: The Statement of Purpose and Service User Guide was provided to CSCI when Care Management Group Ltd took over the ownership of the home. These documents incorporate the use of pictures and symbols. The organisation has a central assessment team based in Wimbledon who undertakes the initial assessment of prospective residents. The Registered Manager confirmed that the home is involved in the assessment process and will make the final decision on admitting a resident. Copies of previous care plans/social services assessments are taken when available. Management will also obtain information from other health professionals, if applicable. Any specialist needs are referred to the Brighton and Hove disability team for advice. The home also has access to the good support systems in place through the use of the organisations specialist health professionals eg. physiotherapist, speech and language therapists. Prospective residents/representatives are encouraged to visit the home prior to moving into the home. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 & 10 Residents’ needs are being met by the information contained in the care plans. Additional risk assessments need to be undertaken to safeguard residents. EVIDENCE: Care plans contain clear information on the needs of the residents. It was confirmed that these documents are being reviewed on an annual basis. The home must ensure care plans are reviewed at least every six months or earlier if the needs of an individual changes. Guidance in the Statement of Purpose reflects that care plans will be reviewed on a six monthly basis. Residents spoken to confirmed that staff discuss their care needs and felt that their needs were being met at the home. Residents were very complimentary about the staff. All of the relative/visitor comment cards received demonstrated that they are satisfied with the overall care provided at the home. Comments received were; ‘excellent care given by all staff’ and ‘I can’t praise the staff highly enough’. It was confirmed that the care plan format is currently being reviewed. There is training arranged for staff on Person Centred care plans. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 10 Residents are encouraged to make decisions and choices that are within their capabilities. It remains an outstanding requirement that risk assessments be undertaken for unguarded radiators and for door locks to individual rooms. As residents participate in kitchen duties, risk assessments must be undertaken for the hot water taps that deliver water above the recommended 43°C. It is recommended that risk assessments be kept under regular review. Personal information is kept confidentially at the home. No resident is capable of managing their own finances. There is one person who is the designated the appointee for all residents. Individuals’ monies spot-checked demonstrated that there are clear records kept of money received and spent. Receipts are kept of all financial transactions. Relatives/representatives have chosen not to take control of any resident’s finances. There is a key worker system implemented at the home and all residents spoken to could identify their key worker. A comment card received from a visiting health professional stated ‘ service users have more choice and there are more varied activities on offer’. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 & 17 Residents are provided with opportunities for personal development and to be involved in the local community. Visitors are welcomed at the home. EVIDENCE: Residents are provided with a range of activities they are able to participate in. On the day of the inspection six residents were taken out for lunch and for the afternoon. The home has its own bus and there is a full time driver available. The home is currently waiting for an updated prospectus from a local college. Residents have previously been encouraged and supported to participate in further education. Residents spoken to confirmed that their lifestyle is their choice and that there are enough activities in and outside the home environment to participate in. It was made a requirement at the last inspection that all swimming sessions under the supervision of staff must have at least one qualified lifesaver present. The home has received funding for three staff to undertake these qualifications. Until staff are trained, the home is using the community pool, where a lifesaver is provided. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 12 Visitors are welcomed at the home. All comment cards received from relatives/visitors demonstrated that they are always welcomed at the home and may visit in private. There is a visitor’s book kept at the entrance of the home that all people must sign when entering and leaving the home. Residents were complimentary about the food provided at the home. Residents spoken to confirmed that they are involved in the planning of the menus and participate in the shopping, preparation, cooking and washing up of the mealtime dishes. It was noted that some residents have been prescribed additional supplements. It is recommended that the prescribed supplement on the MAR charts be reflected in the care plan. The Inspector enjoyed quiche and salad for lunch with the residents. Mealtimes were observed to be relaxed and unhurried. All residents are encouraged to clear their plates into the kitchen when they have finished their meal. Staff also eat with the residents, promoting a homely environment. For those residents who are capable, encouragement and opportunities should be provided to individuals to be involved in cleaning duties and washing their own clothes. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Resident’s needs are being met by the skill mix of staff and support network. Residents are generally safeguarded by the medication procedures within the home. EVIDENCE: Residents and staff spoken with confirmed that they felt there were always enough staff on duty to meet the assessed needs of the residents. The home does not provide nursing care. Due to the complex needs of some residents, staff are required to have a clear understanding of all needs. Health needs are also met with the good support network throughout the organisation and with external health professionals. Two comment cards received from visiting health professionals demonstrated that if they give any specialist advice, it is incorporated into the residents care plan. There is no one capable of self-medicating at the home. There are policies and procedures in place to deal with all aspects of handling medication. MAR charts inspected demonstrated that medication was being signed for at the time of administration. All staff who administer medication has been trained and assessed as being competent. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 14 It is recommended as good practice that any handwritten MAR charts are double checked and signed by staff that have received medication training. Any changes written on the MAR charts must be signed. It was noted that rectal diazepam is prescribed for residents that may have seizures. There is not always a member of staff working at night who is trained to administer rectal diazepam. The home must ensure there are appropriate trained staff on duty at all times. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 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 Residents/representatives are provided with opportunities to air their views. Clear written policies will provide staff with clearer guidance on adult protection procedures. EVIDENCE: There is a complaints procedure available at the home. This needs amending to include the contact details of the local CSCI office. There is a pictorial complaints procedure that residents have access to. There have been no complaints made since the last inspection. There are records kept of any complaints made. Residents spoken to confirmed that they knew who to speak to if they had any concerns. The adult protection policy and procedure needs to clearly state that all allegations of abuse must be referred to social services, who are the lead agency. Information regarding the POVA list needs to be included in this policy. It was confirmed that some staff have received adult protection training provided by the Brighton and Hove Council. In house adult protection training is also provided. Adult protection issues are briefly covered in the induction process. The whistle-blowing policy needs to be amended as it currently only focuses on abuse. It needs to be made clear that whistle blowing can relate to any practices within a home. It is recommended that the contact details of the local CSCI office are included in the whistle blowing policy. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 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, 27 & 30 Residents live in a homely environment. Resident’s needs are currently being met by the facilities provided at the home. EVIDENCE: The home is located in a quiet residential area in Hove. It is two houses that have been joined together. Rooms are located over two floors and residents must be able to independently mobilise to access all areas of the home. The home is not suitable for wheelchair dependent people. The home has been assessed by an Occupational Therapist and some amendments to the environment have been made following the recommendations. There is currently no assisted bathing or showering facilities available at the home. This remains an outstanding requirement. The Registered Manager confirmed that there have been quotes provided for a new bathroom and CMG head office have approved the works to be done in January 2006. The facilities are currently meeting the needs of the residents residing at the home. There has been some decorating undertaken since that last inspection. There are proposals for more work to be undertaken. Rooms spot-checked were 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 17 seen to be personalised to reflect the individuals’ choice and character. Residents spoken with confirmed that they were happy with their individual rooms and are supported by the home if they wish to make changes. The residents sharing a double room have made a positive choice to share. The home was clean and free from offensive odours on the day of the inspection. It remained an outstanding recommendation that the fraying carpet on the stairs leading to the managers’ office on the second floor is repaired. Residents used to have free access to this area. It was confirmed that residents no longer access this area. The manager received permission from CMG head office on the day of the inspection to have this carpet repaired. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 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, 34, 35 & 36 Residents’ needs are at risk of not being met due to insufficient staffing levels. There has been no progress on staff working towards NVQ level 2 or equivalent qualifications. EVIDENCE: Staff spoken with during the inspection process were happy working at the home. Staff commented that they felt the needs of the residents were being met, but they were sometimes short staffed, especially at weekends. The rota provided to the inspector also demonstrated this shortfall. Management must ensure that there are sufficient numbers of staff on duty at all times. Staff spoken with confirmed that they are provided with more training opportunities since CMG took over the running of the home. The rota needs to reflect when the manager is working with residents or on a managerial day. There were some minor shortfalls noted in the staff files inspected. Management must ensure that a full employment history is obtained from all employees and ensure an explanation is provided for any gaps in employment and reasons for leaving previous care positions. All staff files must comply with Schedule 2. A letter is received by the head office of the organisation stating that a CRB check has been undertaken. It is recommended that this letter provides information to the manager if it was clear or not and that a 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 19 POVA check has been undertaken. It is recommended that information regarding a prospective employees’ mental health status be expanded. There was no evidence that the home is working towards achieving the ratio of staff required with NVQ level 2 or equivalent on duty. There is one carer out of 13 that has obtained the appropriate qualifications. This training is arranged by the head office of CMG. Evidence must be provided to demonstrate that work is being done towards achieving the 50 ratio of care staff being NVQ level 2 or equivalent qualified by 31.12.05. There was evidence that staff are receiving supervision every three months. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 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, 40, 41 & 42 Residents and staff benefit from clear leadership within the home. Residents are safe guarded by the systems in place to monitor the health, safety and welfare of residents. EVIDENCE: The manager is registered with CSCI and has the relevant skills and experience to run the home. The manager is currently working towards obtaining the required management qualifications. Residents and staff spoken with were complimentary about the management at the home and find them approachable and supportive. CMG head office sends out their own quality assurance documentation to residents families/representatives/visiting health professionals. An analysis of this survey should be provided to the home so action can be taken to address any identified shortfalls. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 21 Not all policies and procedures were inspected. Any shortfalls in policies and procedures have been highlighted in the relevant section of the report. The home receives policies and procedures from the head office of CMG. It is recommended that a quick reference guide be implemented so staff can quickly access the relevant policy they require. There is a checklist for undertaking an inventory of resident’s belongings on admission. Some were observed to not have been checked or completed. All inventories must be dated and signed upon completion. Records are kept securely at the home and used in accordance with the Data Protection Act 1998. The pre inspection questionnaire demonstrates that all relevant health and safety checks are undertaken. Any shortfalls noted in health and safety have been identified in the relevant sections of the report. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 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 3 x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 2 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 72 - 74 Walsingham Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 2 2 3 x H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 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 YA6 Regulation 15 Requirement Timescale for action 31.10.05 2. 3. 4. 5. 6. That care plans are reviewed at least every six months or earlier if the needs of an individual changes. YA9 & YA26 4 That risk assessments be undertaken for unguarded radiators, door locks to individual rooms and for hot water taps that deliver water above the recommended 43°C. YA14 & 13.4 That during all swimming YA42 sessions where the supervision of service users is the responsibility of care staff, there must be at least one qualified lifesaver present. (Outstanding from previous inspection, see content of report) YA20 18.1(c,(i)) That in the event of rectal diazepam requiring to be administered, appropriate trained staff are on duty at all times. YA22 22.7(a) That the complaints policy includes the contact details of the CSCI office. YA23 13.6 That the adult protection policy clearly states that all allegations of abuse must be referred to social services. Information about the POVA list needs to be H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc 31.10.05 30.11.05 30.10.05 31.10.05 31.10.05 72 - 74 Walsingham Road Version 1.40 Page 24 included. 7. YA23 Appendix 2 16.2(c) That the whistle blowing policy is amended to state that it refers to any practice in the home and not just abuse issues. That assisted bathing or showering facilities be provided in the home for service users who require this. (Revised timescale 01.07.05 not met. That the dependency level of service users and staffing numbers be kept under review and adjusted accordingly. That the rota demonstrates when the manager is working with service users or on a managerial day. That staff files comply with Schedule 2. 31.10.05 8. YA29 31.01.06 9. YA33 18 30.09.05 10. YA33 Schedule 4 (7) 19 Schedule 2 18 24 Schedule 4 30.09.05 11. 12. 13. 14. YA34 YA32 YA39 YA41 31.10.05 That a minimum ratio of 50 of 31.12.05 care staff are qualified to NVQ level 2 or equivalent. That an analysis of the quality 30.11.05 monitoring survey be provided to the manager. That a dated and signed record 31.10.05 is kept of any valuables or furniture brought into the home by a service user. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA9 YA17 YA20 Good Practice Recommendations That risk assessments are regularly reviewed. That the prescribed nutritional supplements on the MAR charts are reflected in the care plans. That hand written MAR charts are double checked and signed by staff who have received medication training. That any written amendments are signed. H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 25 72 - 74 Walsingham Road 4. 5. 6. 7. YA23 YA34 YA34 YA40 That the contact details of the local CSCI office is included in the whistle blowing policy. That clearer information is provided to the manager regarding the suitably of POVA and CRB checks. That information regarding a prospective employees mental health status be expanded. That a quick reference guide be provided for the policies and procedure manual. 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 72 - 74 Walsingham Road H59 H10 S14208 72-74 Walsingham Road V229790 250805 stage 4.doc Version 1.40 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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