CARE HOME ADULTS 18-65
Collinson Road, 95 Hartcliffe Bristol BS13 9PH Lead Inspector
Paula Cordell Announced Inspection 9th November 2005 09:30 Collinson Road, 95 DS0000026573.V250300.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 Collinson Road, 95 DS0000026573.V250300.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. Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Collinson Road, 95 Address Hartcliffe Bristol BS13 9PH 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) 0117 9077215 0117 9699000 The Brandon Trust Mrs Julia Pratt Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 4th May 2005 Brief Description of the Service: 95 Collinson Road is registered with the Commission for Social Care Inspection to provide personal care and accommodation to four people with a learning disability aged between 18 and 64 years of age. 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 home is arranged over two floors with stairs as the means of accessing the first floor. There are two bedrooms and a bathroom situated on the ground floor. The house has the appearance of a domestic dwelling in keeping with the local neighbouring properties. The Brandon Trust, a non-profit making organisation, operates the home. Mrs Julia Pratt is the registered manager. There were no resident vacancies at the time of the inspection. Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The purpose of the visit was to review the progress made to meet the requirements from the inspection in May 2005 and monitor the care 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 in 95 Collinson Road and the provider has sent monthly appraisals of the service. These were used to plan the inspection process. The inspection was conducted over 4.5 hours. The inspector had an opportunity to meet with four residents and a member of staff assisted in the inspection process. There was an opportunity to tour the home and view a number of the records. This included plans of care for two residents and records relating to the general safety and the running of the home in respect of the Care Homes legislation. 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 individuals in leading independent and individualised lives. There is a high level of resident involvement at Collinson Road. There was a clear commitment from staff to encourage independence and empower the 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 people with a learning disability), symbols and photographs. Collinson Road provides a homely environment for the four residents. Collinson Road, 95 DS0000026573.V250300.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. Collinson Road, 95 DS0000026573.V250300.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 Collinson Road, 95 DS0000026573.V250300.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): 1,3,5 Residents have adequate information to make a decision on whether to move to the home. Residents can be assured that the home will meet their assessed and changing care needs. EVIDENCE: Residents have adequate information in the form of a statement of purpose and a resident guide to enable them to chose whether to take up a placement at 95 Collinson Road. Contracts were in place, which met with the legislation. The residents had signed these. The home has not had an admission since 1994. There are four ladies presently living at 95 Collinson Road. Much 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 reassessed and this informed the plans of care for individuals. Standard, 2 and 4, which relate to the admission of an individual was assessed as being in place at the last inspection. The home was able to demonstrate that it was meeting the changing needs of the residents. Care plans were clear and being followed. Evidence was gained from care records, discussion with staff and residents. Three residents spoken with stated that they were happy in the home.
Collinson Road, 95 DS0000026573.V250300.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): 6,7,8,9 Residents could be confident that their care needs were being met, with a strong emphasis on empowerment and independence. EVIDENCE: Two care plans were viewed. Since the last inspection the home has reviewed the documentation and introduced a new format whilst maintaining the individualised approach to the planning of the care for each resident. Care plans 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. Care plans were being reviewed annually and six monthly involving the residents. Care plans demonstrated a commitment to encouraging residents to lead active and independent lifestyles. Residents were offered an opportunity to read their plans of care and daily diaries. This was evidenced by a signature of the residents and confirmed in discussion with residents and staff. The home has recently introduced a monthly summary record for each individual. This is good practice and clearly described activities, health and general wellbeing throughout the month.
Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 Page 10 Care plans were clear, precise, measurable and individually tailored. Residents clearly described the key worker role (named staff allocated to the individual) and described positive relationships with staff. Staff confirmed this commitment to the key worker role and how this was organised on a daily and weekly basis. Residents confirmed their involvement in the day-to-day running of the home including recruitment of staff, regular meetings, menu planning and being actively involved in the choosing of the décor of the home. This was confirmed in documentation, in care plans, resident meeting minutes and in policies. Residents were actively involved in the planning of the day and in household chores and it was evident from discussion with both residents and staff that the individuals living in the home were the focus of this planning. Risk assessments were in place demonstrating that residents were supported in a safe environment. Risk assessments covered a wide range of activities both in the home and in the community. These did not limit individuals but encouraged independence. Residents had signed their risk assessments. This is good practice. Collinson Road, 95 DS0000026573.V250300.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): 11,12,13,14,16,17 Residents lead full and active lifestyles supported by competent staff both in the home and the community. Residents have access to a varied and nutritious menu where there is a high level of empowerment and encouragement towards independent living. EVIDENCE: Documentation in care records demonstrated that the home was meeting the emotional, communication and independent living skills of residents. Residents had planned activities including making full use of the community. Residents were happy to discuss college and their day centre placements. Residents told the inspector that they have a fixed day with their key worker where they can plan an activity of their choice. Activities included shopping, bowling, and the cinema, going for a meal or going for a walk. This was 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 this was positive as it meant 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 DS0000026573.V250300.R01.S.doc Version 5.0 Page 12 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. There was evidence that these were regularly reviewed with the individual to ensure that these were still appropriate and enjoyable. In addition the home organises shiatsu on a fortnightly basis and every three months the home organises a theme day. Staff and residents stated that in the past this has included a beautician visiting the home and external entertainers like the music man. It was evident that these were successful. Residents stated that they had all had a holiday including a trip to Bulgaria and a trip to Weymouth, whilst one resident confirmed that they preferred to take holidays with family. It was evident that the individuals living in the home were the focus of the planning. Holidays and activities were routinely discussed at resident meetings. Residents have access to public transport and the use of staff vehicles. The manager is commended on her advocacy for the individuals in securing additional funding for transport costs to enable residents to attend college. This has been an ongoing issue for the past two years and the manager and residents have been writing to local government officials and Social Services. During this time residents have still continued to attend college courses. Clear records of these additional funds were in place. The home is commended on the communication systems in the home. A number of staff have attended training in non-verbal communication. Residents were involved in all discussions and not excluded. Maintaining contact with families and friends was assessed and met at the last inspection. Relative questionnaires confirmed that the home kept them informed of any changes to the care and that they were made welcome when they visited. It was evident from talking with residents and staff that 95 Collinson Road was the resident’s home. Staff were observed knocking on doors prior to entering. Demonstrating that the home promotes privacy and dignity. Residents were supported to take part in the political voting process, letters were seen on file. This evidenced that this empowerment and being valued as a citizen was encouraged in the wider community. 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.
Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 Page 13 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 DS0000026573.V250300.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18.19.20 The personal and healthcare of individuals living at 95 Collinson Road were being met. However, a review of the administration and the recording of medication must take place to ensure the safety and protection of residents. 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, optician, chiropody, dentist and the community learning disability team. The home has introduced 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 on the administration of medication, including a comprehensive induction and training package for staff. There have been a number of errors in the stock control of the medication in the home and more recently the incorrect dose was given to an individual. Whilst the home had followed the correct procedures it was evident that the label on the medication and the record of administration did not correspond and were not clearly
Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 Page 15 documented. It became apparent that when bank staff were working in the home the staff pre-dispensed the medication and sign for it when in fact the bank staff gave the medication later in the shift. This practice must stop and staff who administer the medication must sign at the time. The home should consider whether pre-printed medication records from the pharmacist would be more appropriate. In addition, bank staff should have training and be competent in the administration of medication. 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 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 all residents had a distinctive individual style this was noted with the choice of haircut and clothes. Residents evidently took pride over their appearance including the use of make up and manicured fingernails. 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. From training records it was noted that many of the staff had attended training in dementia and Down’s syndrome since the last inspection. A member of staff stated that this training was both enjoyable and had increased their knowledge in this particular area of care. Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 Page 16 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): 22,23 Residents have robust complaints procedures, however the policy on protection should be clear on the roles of other agencies involved in the process of investigation and the home must ensure that finances are held securely. EVIDENCE: The home has robust procedures for residents and their representatives to use in the event of a complaint. Relative questionnaires confirmed that representatives were aware of the complaint procedure and confident that the home would respond appropriately. 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 with the Department of Health’s guidance with the reporting of abuse called ‘No Secrets’. This has been unmet since 21/7/04. A member of staff stated that they had contacted the Development manager for the home who confirmed that this would be in place within two months. The policy in the home states that it is the decision of the director of services to make the decision whereas 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. Amounts held in the home corresponded with the records. However it was noted that the safe was open throughout the inspection and cash cards were kept in an envelope with the card numbers.
Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 Page 17 There was a training plan to ensure that all staff attend training in Protection of Vulnerable adults. A member of staff stated that feedback from the course has been good and they look forward to attending in January 2006. Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 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 the following standard(s): 24,26,27,28,29,30 Residents live in a homely clean environment, which is meeting the needs of the individuals living in the home. 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. 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.
Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 Page 19 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. It was noted that the bathroom had damp patches and mould growth at the last inspection. A member of staff stated that a new extractor fan has been installed and this is routinely cleaned. The home has demonstrated compliance with a previous requirement. The home has liaised with a physiotherapist on the aids and 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 DS0000026573.V250300.R01.S.doc Version 5.0 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 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): 32,34, 35 Sufficient, competent and motivated staff support the residents. However, the home should ensure each member of staff has an opportunity to attend training relevant to the care needs of the residents and training records are kept up to date. EVIDENCE: Evidence at this inspection was that the home was adequately staffed. However, staff stated that two staff are on maternity leave and two staff have left for personal reasons. A member of staff stated that the team, or bank staff that are familiar to the residents and the home is covering the shortfall. This was confirmed on the home’s rota. The home employs a minimum of two staff during the day and one sleep in member of staff on a daily basis. In addition there were additional staff rostered to provide opportunities for the key worker (one to one) days and for social activities. This is commendable. It was evident from talking with staff that they were clear about their roles and had a clear understanding of the care needs of the individuals living in the home. Staff were seen during the course of the inspection supporting residents in a positive manner. Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 Page 21 Training records provided evidence that staff were attending training. However, this was not consistent and two staff had not attended training during a twelve and eighteen-month period. It is recommended that staff attend at least 5 days training which is pro-rata for part time staff. Training records seen demonstrated that all staff had attended and were up to date with their health and safety training. It was evident that staff had a number of courses planned throughout the year and some had attended but this had not been recorded onto the training record. There was no confirmation or record that staff had completed their NVQ 2 or 3 on their training records even though through conversation with staff and the pre-inspection questionnaire 5 staff had completed this. Records relating to the recruitment of staff continue to be held at the Brandon Trust. The home has failed to comply with a requirement to ensure that these records are held in the home. This requirement is presently being discussed between the Commission for Social Care Inspection and the Brandon Trust. Non-compliance could lead to enforcement action being considered. Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 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 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): 37,38,40,41,42 Residents benefit from living in a well managed and safe home. 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 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. The Certificate of Registration was displayed in the hallway of the home and reflected the current service. A current certificate of insurance was displayed in the office. The home has a comprehensive policy file, which includes organisational and local policies. All staff had signed the policies as part of an ongoing review and during the induction process. Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 Page 23 All records seen during this inspection were up to date and current. Resident’s records were available in different formats including, sure that staff records are held in the home and available for inspection. Health and safety monitoring was in place including checks on the gas, electrical appliances and the general maintenance of the property. It was evident that these robust systems protect both staff and the service users. Fire records were in order and included checks on the equipment, a record of fire drills and the training of staff. These were at the appropriate intervals. A fire risk assessment was in place. Staff had attended training in health and safety and this was on an annual rolling programme with updates planned throughout the year. Policies and procedures were in place relating to health and safety including risk assessments. These had been kept under review. Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 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 X 3 X 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 4 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 2 X CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Collinson Road, 95 Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 3 X DS0000026573.V250300.R01.S.doc Version 5.0 Page 25 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 YA23 Regulation 13 (6) Requirement Timescale for action 09/01/06 2 YA34 17 (2) Schedule 4.6 3 YA20 13 (2) Schedule 3.3 To review the organisation’s 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) To ensure the records relating to 09/01/06 staff in respect of schedule 4.6 are held in the home. (Outstanding requirement 21/7/04 and 21/12/04) Responsible individual to put in writing how the Trust intends to meet this requirement within one month (9/12/05). The home must ensure that the 10/11/05 prescribed medication is clearly documented on the label and the medication record. Relief (bank) staff must be competent in the administration of medication. Staff who administer the medication are responsible for signing the medication record. Staff must give medication
DS0000026573.V250300.R01.S.doc 4 YA20 18 (1) (c) (i) 13 (2) 10/11/05 5 YA20 10/11/05 Collinson Road, 95 Version 5.0 Page 26 immediately once dispensed. 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 YA35 YA35 YA23 Good Practice Recommendations Staff to attend at least 5 days training per annum pro-rata for part time staff in areas relevant to the care needs of the residents. Training records to be kept up to date. To ensure that the cash cards and the card numbers are held separately. To ensure that safe is locked at all times. Collinson Road, 95 DS0000026573.V250300.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Bristol North LO 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
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