Inspection on 04/05/05 for 95 Collinson Road

This inspection was carried out on 4th May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

95 Collinson Road 04/04/07

95 Collinson Road 09/11/05

95 Collinson Road 21/09/04

95 Collinson Road 21/04/04

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 Collinson Road, 95 Hartcliffe Bristol BS13 9PH Lead Inspector Paula Cordell Unannounced 4 May 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. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Collinson Road 95 Address Hartcliffe Bristol BS13 9PH 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) 0117 9077215 0117 9699000 info@brandontrust.org The Brandon Trust Mrs Julia Pratt Care Home for Younger Adults 4 Category(ies) of LD Learning disability registration, with number for 4 of places Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Not applicable Date of last inspection 21-Sep-2004 Announced Brief Description of the Service: 95 Collinson Road is registered with the Commission for Social Care Inspection to provide personal care to four people with a learning disability aged between 18 and 64 years of age. At the time of the inspection there were no vacancies. The home is situated in a residential area in the South of Bristol at the end of a cul-de-sac. Within half a mile there are shops, bus routes and other local amenities. The house is based over two floors with stairs as the means of accessing the first floor. The house has the appearance of a domestic dwelling in keeping with the neighbouring properties. The Brandon Trust a non-profit making organisation, operates the home. Mrs Julia Pratt is the registered manager. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection. The purpose of the visit was to review the progress to the requirements from the inspection in September 2004 and monitor the service provided to the residents living at Collinson Road. There have been no additional visits during this period. The home has been keeping the Commission for Social Care Inspection informed of incidents that affect the wellbeing of the individuals living at Collinson Road and the provider has sent monthly appraisals of the service. The inspection was conducted over five hours. The inspector had an opportunity to meet with three staff and three of the four residents. The inspector had an opportunity to tour the building and view a number of records including plans of care for three residents, and records relating to the safety and the general running of the care home. What the service does well: Collinson Road is an established home for four ladies with a learning disability. The focus of the care provided was to encourage and support the individuals in leading independent and individualised lives. This was evident in the care planning and the consultation process with the residents living in Collinson Road. Staff were aware of the philosophy of the home and described in great detail how this was put into practice. There is a high level of resident involvement in Collinson Road. Staff that are competent and trained support residents. There was a clear commitment from staff to encouraging independence and the service provided empowered residents. Communication systems in the home were commendable ensuring that information was accessible. This included care plans, menus, staff rota and activities available. Communication systems included makaton (sign language for individuals with a learning disability), symbols and photographs. Collinson Road provides a homely environment for the four residents. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: There are two outstanding requirements, which are the responsibility of the provider (Brandon Trust). The Trust must ensure that residents are protected by a policy on protection, which clearly describes the role of Social Services in leading the process of investigation in the event of abuse taking place in the home. The other relates to recruitment information being held in the home to demonstrate that residents are protected by a thorough and robust recruitment procedure. The manager contacted the Commission for Social Care Inspection the day after the inspection stating that these were in the home. However, as these were not seen this remains a requirement. Residents would benefit from the damp in the bathroom being eliminated. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 7 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. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 8 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 Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 9 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) 1,2,3,5 Residents have adequate information to make a decision to move to the home. EVIDENCE: Residents have adequate information in the form of a statement of purpose and a resident guide to enable them to choose whether they wish to take up a placement in the home. Contracts were in place, which met the legislation. The residents signed these. The home has not had a new admission since 1994. There are four ladies presently living in 95 Collinson Road. The inspector was informed that much of the information from that period had been archived. However, there was sufficient information in care records to demonstrate that the needs of the individuals were regularly being re-assessed and this informed the plans of care for individuals. The home has an admission procedure to guide staff and information was available in the resident guide on the process of admission for residents. The home was able to demonstrate that they were meeting the changing the needs of the residents. Care plans were clear and being followed. Evidence was gained from care records, discussion with staff and residents. Three residents spoke with stated that they were happy in the home. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 10 Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 11 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 The care needs of the residents were being met, with a strong emphasis on empowerment and independence. EVIDENCE: Three care plans were viewed. The home is in the process of changing the documentation over to a new format. Staff were positive about the changes in that they would be more accessible both to staff and residents. Care plans demonstrated a commitment to encouraging residents to lead active and independent lifestyles. Care plans were reviewed annually and six monthly involving the individuals living in the home. The care plans seen were written in different formats to enable the residents to access their own plan of care. These included symbols, photographs and were written in plain English. Residents were offered opportunities to read their plans of care and daily diaries. This was evidenced by a signature of the resident, and confirmed in discussion with residents and staff. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 12 The overall impression was that the care plans were clear, precise, measurable and individually tailored. Residents described positive relationships with staff and a clear understanding of the key worker role where each individual has a named member of staff to support them. Risk assessments were seen in individual care files demonstrating that residents were supported in a safe environment. Risk assessments did not limit but encouraged independence. Residents had signed their risk assessment. Residents spoken with stated that regular monthly meetings were held and that they were involved in the running of the home. Discussions included décor, holidays, menu planning, staffing and activities. Throughout the inspection staff were respectful of maintaining the confidentiality of the residents. Discussions were either inclusive of the resident or conducted in the office with the door shut. This is good practice. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 13 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) 12,13,14,15,16,17 Residents lead full and active lifestyles supported by competent staff both in the home and the community. EVIDENCE: Documentation in care records demonstrated that the home was meeting the emotional, communication and independent living skills of residents. Residents were keen to let the inspector know what they are doing in relation to college courses and social activities. Residents told the inspector that each week a set day is allocated to enable them to plan an activity of their choice with their key worker. Activities included shopping, bowling, and the cinema, going for a meal or going for a walk. This was further confirmed in the diary, care records and the duty rota. This is commendable. This was in addition to other trips, college, and outings planned during the week. Staff stated that this was positive as it meant that quality time was spent with individuals in the home, who are encouraged to make choices and plan outings on a one to one basis. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 14 Residents had access to a combination of college courses, one individual attended a day centre twice a week and a day care worker supported two residents. It was evident that activities were tailored to the individual. In addition the home organises shiatsu on a fortnightly basis and every three months the home organises a theme day. Residents stated that they have manicures and a beauty therapist visits the home. It was evident that these were successful days. A resident stated that they had planned their holiday. There were communication aids to enable residents make informed choices. This is commendable. The home is commended on the communication systems in the home. A number of staff have attended courses in non-verbal communication, further training was planned for the two new staff. Residents were involved in all discussions and not excluded. Residents spoke positively about the contact they have with family and friends. One resident stated that they were organising a party and friends and family were being invited. Residents have an opportunity to attend a club in the evening where they can meet up with friends. Staff spoken with stated that Collinson Road was the residents’ home. Staff were observed knocking on doors prior to entering. Demonstrating that the home promotes privacy and respect. Residents were actively involved in the planning of the menu. Each resident has a cupboard in the kitchen where they can store items of their choice. Residents were observed preparing their lunch and each resident takes it in turns to assist in the main meal preparation, which is eaten in the evening. Residents are given a weekly budget to purchase drinks, snacks and items for they lunchtime meal. This is commendable and enables residents a high level of independence and opportunities to make choices. The records relating to meal planning and menus were clear and demonstrated how the home was meeting the special dietary requirements of individuals. Staff were knowledgeable of the special diets that were taken in the home. There was again a high level of resident involvement. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 15 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) 18,19,20,21 The personal and healthcare needs of the individuals living at Collinson Road were being met. EVIDENCE: Care plans clearly documented the personal and health care needs of the residents. Systems for monitoring an individual’s wellbeing were in place and concerns about health were quickly addressed. Residents had access to other health professionals including a GP, opticians, chiropody, dentist and the community learning disability team. The home is in the process of introducing a new care-planning format for the monitoring of health care. This is good practice and demonstrates a commitment to meeting the targets of the government by introducing Health Action Plans for the individuals expanding on information previously held in the home. The home has robust procedures and practices on the administration of medication, including a comprehensive induction and training package for staff. From talking with residents, staff and reading the care documentation it was evident that the residents were the focus of the care provided. Times were Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 16 flexible to suit the individual in getting up and going to bed including when to eat their meal. This is good practice and demonstrated a resident led service. The inspector saw clear information in care records demonstrating that the home was accessing support and guidance from other professionals ensuring a multi-disciplinary approach. This is good practice. The home has a policy on death and dying. The home has sought the views of service users where possible on the actions the staff should take on the event of their death. This is good practice. Three members of staff told the inspector that the team would be attending training in dementia and Down’s Syndrome in May 2005. This was in response to a requirement from the inspection in September 2005. The home has demonstrated compliance. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 17 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 have a robust complaints procedure, however, the policy on protection should be clear on the role of Social Services in the process of investigation. EVIDENCE: The home has a robust procedure for residents and their representatives to use in the event of a complaint. The home was able to demonstrate that complaints would be listened to and responded to in an appropriate manner. There is an outstanding requirement to ensure that the policy on the reporting of abuse is reviewed to ensure compliance to the Department of Health’s Guidance with the reporting of abuse called No Secrets. The policy in the home states that it is the decision of the director of services to make the decision where as the No Secret’s guidance states that this is the role of Social Services. The timescale for meeting this has been extended to enable the Trust to comply. The home has good financial procedures to ensure the protection of resident’s finances. The home has responded to a recommendation that all financial transactions include two signatures. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 18 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) 24,27,28,29,30 Residents live in a homely, clean environment, however this could be improved by taking remedial action to alleviate the damp in the bathroom. EVIDENCE: Collinson Road is set in a cul-de-sac. The home is situated over two floors and is suitable at present to meet the care needs of the residents. The home has two ground floor bedrooms and a downstairs bathroom. Collinson Road provides a safe place for residents to live and staff to work. The home was clean and free from odour. Residents have single rooms offering them a place of privacy. All residents have a key to their bedroom door. Bedrooms are decorated to a high standard and reflect the personalities of the occupant. Residents told the inspector that they were involved in the cleaning of their rooms. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 19 Communal areas of the home were furnished and decorated to a high standard. The home has a small space to the front of the house and secure rear garden, containing low level planting. There were good systems in place to ensure that the upkeep and maintenance was in order. An annual audit is completed by the organisation to complete a plan of works for the forth-coming year. The bathroom had damp patches and mould growth. A member of staff stated that this has been an ongoing issue and is in the process of being addressed. This area detracts from the other areas of the home. The home has liaised with a physiotherapist on the aids of the adaptations in the home. It was evident that the home has responded appropriately to the assessment of needs demonstrating the home’s commitment to meeting the needs of the individuals living in the home. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 20 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, Sufficient, competent and motivated staff supports the residents. EVIDENCE: Evidence at this inspection was that the home had sufficient staff to meet the care needs of the residents living at Collinson Road. There was evidence that additional staff were rostered to provide residents opportunities to go out socially. The home employs a minimum of two staff during the day and one sleep in member of staff on a daily basis. On the day of the inspection there were three members of staff during the day and three staff in the evening to assist with residents going out. It was evident from conversations with staff that individuals were clear on their roles and the expectations of the service. Job descriptions were in place to guide staff. The inspector was unable to view staffing information as required under the Care Homes Regulations as this is held at the main office of Brandon Trust. This is an outstanding requirement since April 2002. The manager contacted the inspector the day after the inspection by telephone stating that the records were in the home but she was the only person to hold the key to ensure confidentiality of the records. As these were not seen by the inspector this remains a requirement and will be followed up at the next inspection. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 21 Staff spoken to during this inspection described a high level of job satisfaction. Staff described good support mechanisms in place from the manager. Training was in place including an action plan to address shortfalls and future need. This is good practice. The home has responded to a requirement to ensure that staff attend training in dementia. This is planned for May 2005. Training records were updated to include recent training attended. Once a member of staff is employed in the home. They complete a comprehensive induction and the Learning Disability Award Framework after which they will proceed onto completing an NVQ 2 or 3 in care. This is good practice and demonstrates a commitment to providing service users with competent and skilled staff. The home has achieved 50 of the workforce to have an NVQ 2 or 3 by 2005. Staff were seen during the inspection supporting residents in a positive manner. Staff were knowledgeable about their roles as carer and the care needs of the individuals living in the home. During conversations with the staff it was evident that the manager kept them informed of the day-to-day running of the home. Staff spoken with stated that the manager meets with them at least every six to eight weeks individually and as a team every month. This is good practice demonstrating an open and transparent service was being delivered with positive lines of communication. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 22 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) 37,38,39,40,42, The home is well managed. EVIDENCE: Ms Julia Pratt is the registered manager. She has managed the home since 1991 and is a registered nurse for people with a learning disability. Mrs Julia Pratt has successfully completed her NVQ 4 in management in 2002. It was evident from talking with staff and residents that the home remains well managed. The style of management was open, supportive and inclusive. Residents and staff were consulted on the delivery of care and matters relating to the running of the home. Staff stated that they felt supported and had a clear sense of purpose in their roles within the home and support given to residents. The home has a system for reviewing the quality of the care provision. This is good practice and informs the home’s business plan. This was displayed on the Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 23 staff notice board. Staff were aware of the plan further demonstrating their level of involvement. This is good practice. In addition the organisation was visiting the home and in line with the Care Homes Regulations. The Commission for Social Care Inspection were receiving copies of the monthly reports. The fire records were reviewed on this occasion, as there were a number of concerns raised at the inspection in November 2004. It was evident that this has been addressed with regular checks being undertaken on the equipment and training for staff. A fire risk assessment has been completed. Other systems to ensure the health and safety of staff and residents were in place including risk assessments, policies and audits on the premises and equipment. A training plan is in place to ensure that staff attend periodic updates on health and safety. The home has demonstrated compliance to a previous requirement. All records relating to the running of the home were found to be in order. The home is commended on the accessibility of the care records and the resident involvement. The home must ensure that staff records held in the home are available for inspection. Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 24 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 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 4 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 4 3 3 4 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Collinson Road, 95 Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 2 3 x D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 25 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 23 Regulation 13 (6) Requirement To review the organisatons protection of vulnerable adults policy to ensure compliance with the Department of Health No Secrets. (Outstanding requirement from the 21/7/04 and 21/12/04) For the home to alleviate the damp in the bathroom To ensure the records relating to staff in respect of schedule 4.6 are held in the home. (Outstanding requirement 21/7/04 and 21/12/04) Timescale for action 4/8/05 2. 3. 27 34, 41 23 (2) (b) 17 (2) Schedule 4.6 4/8/05 4/8/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG 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 Collinson Road, 95 D56 D05 S26573 Collinson Road V196561 040505 Stage 4.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. 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