Inspection on 15/05/06 for Azalea House 1

This inspection was carried out on 15th May 2006.

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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Azalea House 1 24/10/08

Azalea House 1 09/07/08

Azalea House 1 16/08/07

Azalea House 1 07/09/06

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 Azalea House 1 71 Winifred Road Bedford MK40 4EP Lead Inspector Dragan Cvejic Unannounced Inspection 15th May 2006 09:00 Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 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 Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 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. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Azalea House 1 Address 71 Winifred Road Bedford MK40 4EP 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) 0870 609 2432 Minster Pathways Limited Jan West Care Home 4 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (4) of places Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24/08/2005 and random focused inspections on: 28/11/2005 and 06/04/2006. Brief Description of the Service: Azalea Services are two privately owned care homes situated in a residential street on the west side of Bedford. The two adjacent houses operate in conjunction with each other. House 1 is registered for 4 service users who have a diagnosis of learning disabilities and mental health needs; house 2 is registered for 3 people in the same category. The purpose of the service is to offer appropriate support for service users, including developing or maintaining their independence skills. This house is used as a main project base, accommodating the office and the main documents for service users from both houses. The house is a large domestic property and offers 4 single bedrooms, a lounge, bathing facilities, and a dining room and kitchen. There is a garden at the back that connects the two houses. The new owner will carry out major re-development and refurbishment of the houses. The plan is that the office is to be moved into an extension in the back garden, the refurbishment of bathrooms and laundry facilities takes place and generally environmental standards are improved. The house is located approximately one mile from the town centre and within walking distance of local shops, pubs and transport links. The fee quoted by the manager was in the range of £1179-£2000. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out using new inspection methodology and included two site visits. The first visit results were produced in a separate letter and presented the requirements separately. The second visit was used to check the progress of the previously set requirements and to ensure that all key standards were inspected. The home produced information about the services provided in a pre-inspection questionnaire. Two visitors comment cards noted that service offered good care to service users. The site visit was used to inspect standards by case tracking 3 service users, speaking to 2 staff members and to the manager and observing staff offering care and support to service users. The immediate requirement set on the previous site visit was only partly met, but the risk to service users and staff was minimised and kept at that level. The home was going through many changes since the change of ownership. Their progress was significant. The manager was considering equality and diversity in the service when the review and analysis of service users and staff was carried out. What the service does well: What has improved since the last inspection? A statement of purpose and service users’ guide had just been received from the head office and the home now had written information about the service. Newly sorted and consolidated care plans and user’s files clearly presented goals for each individual. A record of complaints now contained the outcomes. Although the washing machine had not yet been replaced, a safe procedure was introduced for using the laundry room at 69, Azalea’s second house, that ensured safety for staff and service users. The plan to use it worked very well. Recent recruitment was successful and two new staff had been offered employment, completing the staff team. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 6 Manager and staff familiarised themselves with new policies and procedures introduced by the new owners. 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. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 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 Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 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): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. The home had a good admission procedure, including written information, to provide service users with the opportunity to make an informed choice about the home and make sure that their needs would be met. EVIDENCE: The home received a statement of purpose and a service users’ guide from the new owners. However, the statement of purpose had not yet been sent to CSCI. The manager stated that she was not sure how much influence she could have over these documents. Recent visits by a prospective service user demonstrated that the manager would carry out full assessment prior to offering a place. All 3 service users spoken to confirmed that their needs were met. The new owners were assessing the old contracts in order to produce new ones, relevant to the changes they had introduced. Service users’ files still did not contain contracts. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 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 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. Care plans were written in the new format set by the new owners, contained set goals and service users were aware of the basic aims set in care plans and risk assessments. EVIDENCE: Care plans covered all main aspects of service users’ assessed needs and had clear set goals. Risk assessments, a part of the plans, were also comprehensive and service users knew the hazards. Care plans were reviewed regularly which was recorded on evaluation sheets. However service users or their representatives did not sign their care plans. Service users spoken to stated that they could make decisions about their life. Records of different meals chosen by service users, weekly programmes and individually chosen activities in the home demonstrated how users kept control over their lives. Relatives and families were either appointees for service users’ finances, or helped them manage their money. Two service users spoken to stated that they liked going out, but with staff, as they felt more secure and safer with staff accompanying them. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 10 The manager was going to devise some home policies, not covered by the company’s policies and intended to involve service users in creating them. A care plan showed how a service user had progressed with his smoking habit, firstly having restrictions and being under full staff control, to the point where he eventually became responsible for his smoking and kept it at an agreed level. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 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): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. The home offered choice to service users in choosing their lifestyle, their activities and to form relationships as they wanted. EVIDENCE: A weekly activity programme was agreed and displayed on the notice board for each individual. This way, users were encouraged to develop their own initiative, but also their responsibility. Lists for case tracked service users demonstrated that activities were meaningful and included attending college, baking cakes at home, swimming, going out with staff for pub lunches, going to the library or, as they chose, just resting at home with music or TV. This programme covered different times during the day and included evenings. Service users were observed interacting with each other and with staff, and their relationships seemed friendly and supportive. Service users had meetings where they chose the menu, discussed any issue they wanted to discuss among themselves and were informed of any news within the home that would potentially affect their life, such as recent building work and plans on how to use laundry at 69 temporary. Most service users Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 12 held the keys to their bedrooms. Service users moved freely between houses and enjoyed that freedom. The cleaning of their bedrooms was agreed with each individual and incorporated into their activity plan. One service user kept an aquarium with fish and staff helped him with this when he required. Rules on smoking and alcohol were an important part of the care process and three service users stressed how they were supported to follow and respect these agreed rules. The cooking rota enabled users to cook in turns for the whole house the meal they chose. A service user stated that he was not a keen cook but understood responsibility for sharing duties within the home. The menus showed breakfast, a mixture of cooked and cold lunches and cooked dinner. Fresh fruit was on a table during the site visit. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. The staff encouraged independence, but also supported service users to meet all their healthcare needs. EVIDENCE: A service user came for a shower and asked staff: “Can I…” The staff member encouraged him to proceed with his plan. Another user was encouraged, again politely, to use a dressing gown, for comfort and for respect for other users. She returned with the gown on and with a smile. The staff team had a mixture of male and female staff to respond to the personal care needs as service users wished and had a choice of staff gender to help them. Service users’ files documented the involvement of external health professionals and included basic healthcare needs, such as dentists, chiropodists and more specialised mental health professionals. One of three case tracked service users stated that he “rarely sees” any CPN or social worker. The manager explained that his social worker had indeed been absent from work for a long time and that the home was discussing with the social work department the way forward for this particular service user. Key working system was in place. The records were kept to monitor frequency of dental, opticians and chiropody appointments. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 14 Medication was stored, recorded and administered appropriately. The staff had good knowledge of medication. Service users were also well informed about their medication. A service user stated: “I would like to get off this medication, eventually. I know I have to discuss this with my doctor.” The staff were aware of his wish. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. The home had an effective complaints procedure that enabled service users to express their opinions and potential dissatisfaction. Protection of service users was generally ensured by safe working practice, but needed to be expanded by staff’s appropriate training. EVIDENCE: The home had received one complaint since the last inspection. The investigation and the outcome were recorded in the records of complaints. A concern expressed by a service user was also satisfactorily resolved. Not all staff were trained on POVA, so the manager provided temporary guidance for staff on how to deal with potential allegations. Service users were aware of the procedure and knew that they could complain if they wished. The families were supporting service users with their finances. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. The new owners arranged for work to start on improving the environment and making it more comfortable for service users and staff, while the staff ensured that the effects of the work on service users were minimal. EVIDENCE: The homes location in a side street provided a comfortable place for service users to live in. A service user commented: “It is so nice and peaceful here.” The new owners decided to improve the property and, by the time of the site visit, two bathrooms were refurbished. The builders were working according to plan, while the staff organised life in the home in such a way that service users were not affected by the work. All service users from this home and the house next door felt free to walk in and use the facilities in any of the two houses. A laundry room in this house was closed temporary until builders complete their work and new washing facilities are installed, but the service users used a laundry facility in no. 69, the house next door. Although the garden was affected by the works, it was made safe for service users to use if they wished. The manager had just completed reviewing new COSHH sheets. The staff and manager ensured that infection control measures were in place. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 17 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): 31,32,33,34,35 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. The fully staffed team achieved recently after latest recruitment ensured that consistent and appropriate care was provided for service users who felt supported and well looked after by trustworthy staff. The ongoing training for staff was not being delivered which increased the risk of service users being managed inappropriately. EVIDENCE: The home had carried out a recruitment since the last inspection and compiled a full staff team. One new worker had started on the day of the site visit and the other would start as soon as the second reference arrives. This would reduce the use of casual, bank staff and ensure more consistent and stable care. Rota showed that staff were deployed according to the assessed needs of service users and daily routine. Two staff confirmed that they knew their roles and responsibilities. The staff had the skills and experience to meet the needs of service users. They developed a good professional relationship with service users and demonstrated their caring and supportive attitude during the inspection. The atmosphere in the home and the organisation of work resulted in service users’ satisfaction and trust from service users. The level of NVQ trained staff was 25 . Two service users stated that the staffing level was appropriate and that staff were able to respond to their needs. The staffing composition ensured that Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 18 service users could be supported by their preferred gender of staff. Regular staff meetings were reinstated since the change of ownership. The recruitment of the two last staff members showed that the home ensured that recruitment was carried out appropriately. Staff did not start work before the home obtained all relevant documentation necessary so that the protection of service users was ensured. Training was not up to date. New ownership and the company’s approach to training caused a break in refresher courses. The staff team and the manager identified necessary training and submitted request to the head office, but it was not clear who by, how and when the training gets booked. The manager’s autonomy in this area was reduced, but the procedure and new responsibility were not clear. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 19 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): 37,38,39,40,41,42,43 Quality in this outcome area is poor. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. The on site management of the home was improving, but there were still deficits in key areas which the Company needs to address. The poor level of communication of delegated responsibilities with the manager is causing confusion and this leads to a continued risk to service users. EVIDENCE: The manager reviewed new policies and procedures introduced by the new owners. As most policies were the company’s own, this task was time consuming. The manager’s findings that a certain policy was not directly relevant to this particular home, or was missing, would need to be addressed locally, so that the manager, staff and service users, use their own initiative to create relevant policies. This would also provide the missing evidence whereby service users take part in reviews of the home’s policies. The manager was aware that users’ contracts were not clear and needed to be addressed. However, the day-to-day operation of the home was organised and ran smoothly. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 20 The manager stated that communication with head office and through the company structure was not consistent, and did not clearly divide responsibility. One example was booking training. Quality assurance review was not carried out and the system for it was not clear to the manager. A limited survey carried out with service users was not effective and did not give clear outcomes. This is subject to a requirement where extended timescales have been given on previous inspections. This still requires action by the Company as a matter of priority. Policies and procedures needed review at local level to identify any potentially missing or irrelevant detail that would need to be addressed. The manager was reviewing these policies. She was not clear how to instigate amendments if they were necessary. Service users’ records were up dated. Training that was not up to date influenced safety and security within the home. Not all staff had up to date fire, food hygiene, and medication training. POVA training was also seen as a priority to book and attend. Risk assessments needed to be reviewed almost daily to assess any potential risk arising during building work on site. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 21 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 Standard No Score 1 2 2 3 3 3 4 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 2 1 2 3 1 1 Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 22 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 YA1 Regulation 6 Requirement The home must review the statement of purpose and the service user’s guide to illustrate the change of ownership and forward reviewed and updated copies of these documents to the CSCI (This requirement was issued on previous inspection and the time scale did not expire for the home to comply with it.) Service users must have an up to date contract that addresses all points from standard 5. (This requirement was set on the previous inspection with deadline 15/05/06. The manager explained that the company was looking into this issue and a new time scale was set on this inspection.) Timescale for action 30/05/06 2. YA5 5 15/06/06 3. YA27 23 4. YA28 23 The bathrooms and toilets must 30/07/06 be maintained as in the organisation’s plans, but not later than specified in this report. (This requirement was set on the previous inspection and the time scale has not expired.) The planned kitchen 15/09/06 DS0000066699.V294661.R01.S.doc Version 5.1 Page 23 Azalea House 1 5. YA30 23 6. YA32 18 7. YA32 18,19,13 refurbishment must be completed by the stated date (This requirement was set on the previous inspection and the time scale has not expired.) The laundry equipment must be replaced and made safe. An immediate requirement not to use laundry was issued as the equipment represented a serious hazard.(07/05/06) (This requirement was set on the previous inspection and the home made plans for the safe use of the laundry room in the Azalea 2 house that ensured the safety of staff and service users. Building work on the refurbishment of the laundry room was currently carried out and new time scale was set for full compliance with this standard.) Staff must have the competence to meet the service users needs, gained through training on service users’ specific conditions. The NVQ programme must continue to ensure that at least 50 of staff are NVQ trained. Staff training plan must demonstrate that steps are taken and training is planned. (This requirement was set on the previous inspection and the time scale has not expired.) The manager and staff should attend up to date training on benefits to be able to appropriately support service users and protect their legal rights. (This recommendation was set on the previous inspection and the new training plan must be part of it.) All staff working with service users in the home must attend DS0000066699.V294661.R01.S.doc 30/06/06 30/07/06 30/07/06 Azalea House 1 Version 5.1 Page 24 8. YA35 24 and keep up to date their training on Protection of Vulnerable Adults. Ensure that all staff receive the 30/07/06 training appropriate to their roles including any specialist training tailored to service users’ conditions. (Previous timescale of 31/7/05 not fully met). Timescale of 30/11/05 not yet elapsed. New owners’ training plan must be made to address this, previously unmet requirement. (This requirement was set on the previous inspection and the time scale has not expired.) The plan was submitted and training must be booked and dates of bookings sent to the CSCI and cover all identified training subject as submitted in the pre-inspection questionnaire. 9. YA38 24 10. YA39 24 The manager must review 30/07/06 quality of care and services with procedures and policies to ensure that clear leadership, guidance and directions are provided and clear to staff and service users within the home. The manager must be clear of her duties, responsibilities and accountabilities. 30/06/06 Introduce quality assurance and monitoring systems including service user questionnaires and lifestyle audits. (Previous timescales of 29/2/04, 30/11/04, 31/3/05 and 31/8/05 not met). The new organisation must ensure that a quality assurance programme is in place, as this requirement was not met by the previous ownership. (This requirement was set on the DS0000066699.V294661.R01.S.doc Version 5.1 Page 25 Azalea House 1 11. YA40 24 12. YA42 13 13. YA43 24 previous inspection and the time scale has not expired.) The manager must ensure that appropriate written policies and procedures are in place for the management of the home and provide evidence of consultation with service users and their representatives about the policies and procedures. The staff must have up to date training to ensure safe implementation of safe practices and procedures and ensure the safety of service users. The new owner must make clear lines of accountability within the home to ensure effective management process was in place. 30/07/06 30/08/06 30/07/06 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 YA6 Good Practice Recommendations The manager should try to obtain service users or their representatives signature on care plan to evidence their involvement. Azalea House 1 DS0000066699.V294661.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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. 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