Inspection on 10/10/05 for 85 Lodge Lane

This inspection was carried out on 10th October 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

85 Lodge Lane 07/08/07

85 Lodge Lane 14/12/06

85 Lodge Lane 09/08/05

85 Lodge Lane 11/01/05

85 Lodge Lane 13/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 85 Lodge Lane Low Town Bridgnorth Shropshire WV15 5DF Lead Inspector Rebecca Harrison Unannounced Inspection 10th October 2005 09:45 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 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 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 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. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 85 Lodge Lane Address Low Town Bridgnorth Shropshire WV15 5DF 01746 766832 01746 766832 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) MacIntyre Care Care Home 5 Category(ies) of Learning disability (2), Physical disability (3) registration, with number of places 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: 85 Lodge Lane is a semi-detached property situated on a residential estate on the outskirts of Bridgnorth, Shropshire. The property is owned by Shropshire Health Authority. MacIntyre is a voluntary organisation contracted to provide a care service. The home is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care to a maximum of five adults with a learning disability and physical disability. Service users are provided with a single room. Bedrooms for individuals with mobility difficulties are situated on the ground floor. The property is in keeping with the local community. MacIntyre have a mission statement in place, which is ‘To be recommended and respected as the best provider of services for children and adults with learning disabilities throughout the United Kingdom’. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home currently has no vacancies and there have been no new admissions or discharges since the last inspection. The manager of the home is Ms Jo-Anne Jones, who has been in post since 4th January 2005. She has applied for registration with the CSCI and a fit person interview is scheduled for 20th October 2005 to assess her fitness. The inspection was unannounced and commenced at 09.45 and lasted just under 3.5 hours. The Lead Inspector was Ms Rebecca Harrison. The Provider Representative was Ms Jo-Anne Jones, Head of Service. This is the second inspection undertaken by CSCI since 1st April 2005. The purpose of this inspection was to review the progress made by the home since the last unannounced inspection undertaken on the 9th August 2005. Twenty-one requirements and two recommendations were made as a result of the last inspection. This inspection included talking with service users, the manager, staff on duty, examination of a number of records and a full tour of the home. The manager, staff and the service users were welcoming and very helpful throughout the inspection process. No complaints have been received by the home or referred to the Commission for Social Care Inspection since the home was last inspected. There have been no referrals made under adult protection procedures. The inspection overall was positive with the work undertaken by the team and the commitment shown in meeting a large number of requirements previously made acknowledged by the inspector. What the service does well: The people living at the home are well cared for and are supported by a staff team who work positively and have a good knowledge of individual likes, dislikes and interests. Service users are supported and encouraged to keep in contact with their families and friends and are provided with a comfortable environment to live. Staff are provided with good training opportunities. The home employs 14 care staff with ten staff holding NVQ awards at level 2 or 3. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 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 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&5 Appropriate procedures are in place that would enable the successful admission of new service users to the home. EVIDENCE: There have been no new admissions or discharges since the home was last inspected. The home has no vacancies. Two requirements were made at the previous inspection for the Statement of Purpose, Service User Guide to be updated to reflect the new managerial arrangements and that the Service User contract be updated and produced in a format appropriate to the needs of the people accommodated. The findings of this inspection evidenced that all three requirements previously made have been met and a copy of all documents maintained on individual care files. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Staff are provided with the information they need to satisfactory meet the assessed needs of the individuals accommodated. The current people accommodated at the home are unlikely to be able to contribute to decision-making processes due to their disabilities. Service users are enabled to take responsible risks within a risk-assessed framework. EVIDENCE: Two requirements were made at the previous inspection in relation to care planning and that these be more detailed to contain all aspects of personal, social support and healthcare and be reviewed with the service user and significant others at the required frequency. The manager reported that all but one of the care plans now contain more detailed information to ensure that staff are provided with sufficient information for care delivery and that this is provided in a consistent manner. A review has been scheduled for the person most recently admitted to the home. The care plan will be reviewed and updated with the service user, family and significant others during this meeting. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 10 The manager reported that she has liaised with the placing authority in relation to reviewing the other four people accommodated at the home. The reviewing officer is currently off sick and no other person has yet been identified. The manager was advised to schedule reviews in the interim and forward dates to relevant bodies and copies of the minutes. A requirement was made at the previous inspection for service users to be enabled in the development of and review of the policies and procedures, statement of purpose etc thorough the use of advocates, family etc. The manager reported that she has liaised with a local citizen advocacy service who are currently experiencing difficulties with recruiting advocates. Currently Link workers and members of service users’ families advocate on behalf of the people accommodated at the home. The manager reported that she and the senior support worker plan to meet with families to discuss the service provided etc. Discussions held with new staff indicated they had a good understanding of individual’s preferences. Two requirements were previously made in relation to the management of risk. These were for generic and individual risk assessments to be reviewed and updated and for assessments covering all activities and holidays undertaken by service users be developed and implemented and included on service user care files. The findings of this inspection evidenced that this has been met. The manager who received training in risk management following her appointment has completed risk assessments. Ms Maria Tole, Service Manager has commenced countersigning all risk assessments. Risk assessments will now be reviewed every six months or earlier if required. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): X EVIDENCE: The intended outcomes for standards 12,13,14 and 15 were assessed and met at the previous inspection of this home undertaken on 09.08.05. Key standards 16 and 17 will be reviewed at the next inspection of this service. A recommendation was made at the previous inspection for in-house activities to be developed, structured and recorded. Progress has started to be made with service users recently enjoying a sensory evening. Observations made evidence that further work is required in this area and this was fully acknowledged by the manager who reported that in-house activities was discussed in a recent team meeting. It was reported that all activities undertaken are recorded on daily record sheets. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Service users are protected by the improved medication systems now in place. EVIDENCE: The intended outcomes for key standards 18 and 19 were reviewed and met at the previous inspection. The outcome for key standard 20 was reviewed and not met at the previous inspection. Three requirements were previously made in relation to medication. These were for medication to be administered as per the prescriber’s instructions, expired medicines to be returned to the pharmacy for disposal and staff responsible for the administration of medicines to receive accredited training. The manager reported that following the last inspection procedures have been improved. The senior support worker has devised a medication audit checklist and has designated responsibility for the management of medicines in the home. Accreditied training has been scheduled for the end of October through Ludlow college. In addition to this, staff are to attend a one day training event arranged through Boots Chemist in December 2005. Examination of records and the medication cabinet evidenced that the other two requirements made have now been met. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a satisfactory complaints procedure and systems are in place to safeguard service users from potential abuse. EVIDENCE: Requirements were made at the previous inspection in relation to complaints and protection. These were for the home to update the complaints procedure to reflect the new name of the regulatory body, for staff to be provided with training on the local adult protection policy and procedures and for the policies in relation to service users finances be reviewed and updated. Two of the three requirements have now been met. The timescale made for the policies in relation to service user finances to be reviewed and updated is 01.11.05; therefore this requirement has been brought forward and will be reviewed at the next inspection of the service. The manager reported that all day staff and two relief staff have now received training in the local adult protection policy and procedures. Training is to be arranged for waking night staff. ‘A Service User Guide to Making a Complaint’ has been developed and implemented in August 2005. Each service user has been provided with a copy and these were seen on the care files reviewed. No complaints have been received by the home or referred to the Commission for Social Care Inspection since the home was last inspected. There have been no referrals made under adult protection procedures. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 Service users are provided with a clean, homely and comfortable place to live. Consideration should be given to the long term plans for the home due to the increasing dependency levels of the people currently accommodated and safe working practices. EVIDENCE: The home offers access to local amenities, transport and relevant support services and is safe and generally well maintained, clean, comfortable and is in keeping with the local community. The two people who are permanent wheelchair users are provided with accessible accommodation on the ground floor and have access to the garden. A further single room is provided on the ground floor and a further two single rooms are provided on the first floor. En-suite facilities are not provided. Room sizes are documented in the homes Statement of Purpose. Two rooms are 10.4 sq.m, two are 10.7 sq.m. and one room is 12.2 sq.m. Although the home is an existing registration and the new national minimum standards do not apply to room sizes, consideration should be given to the increased dependency levels of the service users currently accommodated, the lack of storage for specialist equipment and the space required for undertaking safe working practices. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 15 An inspection by the Fire officer was undertaken on 14th January 2005. Fire safety arrangements were found satisfactory and no recommendations were made. The manager reported that the Environmental Health Officer has not visited the home since she came into post on 04.01.05. Shared space includes a lounge, an open style kitchen/diner and a small garden. Although the home appears to be comfortable there are areas that are in need of redecoration. The manager advised that some new furniture, furnishings and kitchen equipment are to be purchased shortly and there are plans to redecorate the lounge and kitchen/diner however the carpets in the lounge and hallway do become easily soiled despite regular cleaning. Service users bedrooms have been personalised and reflect their individual lifestyles and appear comfortable. The home provides a bathroom located on the ground floor and this is fitted with an aqua nova bath. A further bathroom is located on the first floor. Records seen evidence that staff test and record water temperatures prior to individual’s bathing. The home provides provision of environmental adaptations and specialist equipment however there is very limited storage space, with hoists being stored in service users bedrooms which are already very limited in space. The home was found very clean, tidy and free from any offensive odours. Domestic staff are not employed and it is the responsibility of the care staff to undertake domestic, catering and gardening duties in addition to their care role. The organisation has an infection control policy in place and the manager has developed local guidelines for good hygiene, dated March 2005. The home provides appropriate washing facilities and arrangements for the disposal of clinical waste. It was reported that the support worker who undertakes health and safety responsibilities has attended training in infection control. A waking night member of staff has designated responsibility for COSHH. The necessary data sheets are stored with the products and the file seen was organised and well presented. Cleaning schedules are maintained on a daily basis by the team. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 36 Services users are supported by a competent, committed and well-trained staff team. EVIDENCE: A requirement was made at the previous inspection in relation to staffing levels and that these be reviewed in order to meet the assessed needs of the people accommodated, ensuring their safety and that of the staff team. The manager reported that she has had discussions with the service manager, Ms Tole and that staffing has increased to three staff on two or three evenings of the week, thus providing greater opportunities for people to access the community. The manager reported that the home is now fully staffed with the exception of a ten-hour waking night post. She stated that she is confident that the home now provides adequate staffing levels to support the people accommodated. The manager was advised to keep staffing levels under review due to the increasing level of need of the people accommodated and also to provide greater opportunities for community presence and participation particularly after 3pm as recommended at the previous inspection. New staff spoken with reported that they have been provided with good training opportunities. During the six-month probationary period they are expected to work through a Personal Development Portfolio. A copy of such was seen at the inspection and this was very comprehensive. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 17 New employees are expected to complete the induction units of the Learning Disability Awards Framework- ‘Certificate in Working with people who have Learning Disabilities’ (CWPLD). Staff have accessed mandatory training and through appraisals staff are identifying training for their own personal development, which is service specific. The manager stated that on completion of the personal development reviews she intends to complete a training and development plan for the team. It is positive to report that more than 50 of the staff team have achieved an NVQ Care Award. Two requirements were previously made for staff to receive a minimum of six supervisions per year and have an annual appraisal to review performance and agree a career development plan. The manager has developed a record in the back of the communication book for staff supervisions, the dates and signatures of the supervisees. A supervision monitoring form of all supervisions undertaken has also been developed and a copy sent to the Service Manager. The manager reported that three appraisals have been undertaken since the last inspection and appraisals have been booked to take place before the end of October with the exception of a waking night staff and a new employee who is on a six-month probationary period. The two most recently appointed staff spoken with during the inspection stated that they feel well supported by the manager and the team. Both the new staff have had previous care experience and discussions with them evidenced that they appear well motivated and committed to their work. Regular team meetings are in place. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,40,41,42 and 43 The manager has a good understanding of the areas in which the home needs to improve. The home continues to make progress towards raising the standard of record keeping. The safety and welfare of service users and staff are not fully promoted. EVIDENCE: Ms Jo-Anne Jones is the Head of Service and commenced working at the home on 4th January 2005 and has applied for registration with the CSCI. A fit person interview has been scheduled for 20th October 2005 to assess her suitability. Ms Jones is line managed by the Service Manager, Ms Maria Tole. The manager reported that she receives regular supervision and support from Ms Tole. A requirement was made at previous inspections for the manager to obtain qualifications at level 4 NVQ, in both Management and Care. The manager 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 19 reported that she is to commence her NVQ level 4 Care award on 12th October 2005. Following the inspection the manager telephoned the CSCI local office to report that she has since registered to undertake the Registered Managers Award. The timescale made for the review or implementation of policies and procedures on topics outlined in Appendix 2 (2nd edition of the NMS, Care Homes for Adults 18-65) is 01.11.05 and therefore will be reviewed at the next inspection. The manager has identified a list of outstanding policies or those in need of review and will ensure these are service specific. A requirement was previously made for all records required by regulation for the protection of service users and the effective and efficient running of the home be maintained, up to date and accurate. It is positive to report that since the last inspection progress has been made and record keeping systems are improving. Permanent and relief staff have undertaken a number of mandatory health and safety training courses as required of the last inspection. The manager reported that staff have completed first aid, moving and handing, adult protection and fire. Food hygiene training has been scheduled for November and December and medication in October and a day in December. The support worker with designated health and safety responsibilities is also to receive the appropriate training to support her in this role. New staff are currently undertaking induction training. Bed rails have been fitted to the beds of two service users and risk assessments have been undertaken to support their safe use. However on inspection of the rails one bed was found fitted with ‘odd’ rails. The manager reported that one of the rails has recently been replaced. Discussions indicated that the rails are ordered following an assessment and fitted by the staff that have not received training in bedrails, their suitability and compatibility with the bed. The bedrails on both beds were found to be very loose and are not checked as part of the routine maintenance. Risk assessments for safe working practices were not available for inspection. The manager reported that these have been reviewed and new ones developed and are with the Service Manager to be countersigned. A valid certificate of insurance in respect of liability has been obtained and this was seen displayed next to the office. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 20 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 3 x x x 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 85 Lodge Lane Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x 2 3 2 3 DS0000020724.V255662.R01.S.doc Version 5.0 Page 21 YES 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 (2) Requirement All care plans must be reviewed with the service user (involving significant professionals, family and advocates) at the request of the service user or at least every six months and updated to relflect changing needs; and agreed changes are recorded and actioned. Policies for the management of service users finances must be reviewed and updated (brought forward from previous inspection). A planned maintenance and renewal programme must be developed and implemented. The manager must obtain qualifications at level 4 NVQ, in both Management and Care. Policies and procedures must be developed reviewed and amended on topics outlined in Appendix 2 (2nd edition of the NMS, Care Homes for Adults 1865). The manager must ensure these are specific to the home. (Brought forward from previous inspection). DS0000020724.V255662.R01.S.doc Timescale for action 30/11/05 2 YA23 16(2)(1) 20 01/11/05 3 4 5 YA24 YA37 YA40 23 9 12,13,16, 17,18,19 30/11/05 31/12/05 01/11/05 85 Lodge Lane Version 5.0 Page 22 6 YA42 12(1) 13(4)(5) 13(4)(6) 7 YA42 Risk assessments for safe 17/10/05 working practices must be retained in the home and accessible to staff at all times. Staff who are responsible for 17/11/05 selecting, fitting and checking bed rails must receive appropriate training and bed rail assemblies should be included on a planned maintenance schedule. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA14 Good Practice Recommendations it is recommended that in-house activities be further developed and structured. 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 85 Lodge Lane DS0000020724.V255662.R01.S.doc Version 5.0 Page 24 - 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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