Inspection on 15/11/06 for Baldock Core & Cluster

This inspection was carried out on 15th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Baldock Core & Cluster 14/11/05

Baldock Core & Cluster 07/06/05

Baldock Core & Cluster 07/12/04

Baldock Core & Cluster 28/07/04

Similar services:

Claremont House

Chesham House

Argyll House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

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

CARE HOME ADULTS 18-65 Baldock Core & Cluster 17/18 Coach House Cloisters 10 Hitchin Street Baldock Hertfordshire SG7 6AL Lead Inspector June Humphreys Unannounced Inspection 15th November 2006 10:00 Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 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 Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 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. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Baldock Core & Cluster Address 17/18 Coach House Cloisters 10 Hitchin Street Baldock Hertfordshire SG7 6AL 01462 491141 01223 576750 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) Granta Housing Society Limited Karen Lawrence Care Home 30 Category(ies) of Learning disability (30), Learning disability over registration, with number 65 years of age (30), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1), Physical disability (30), Physical disability over 65 years of age (30) Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. This cluster may also accommodate people with physical disability (when associated with a learning disability) aged 18-65 years or over 65 years. The registration category of MD(E) applies only to the resident currently living in the scheme and will cease once the service user is no longer resident in the home. All care staff must receive certified training in Mental Health care. Current emergency strategies that are in place are reviewed on a regular basis to ensure the health, safety and wellbeing of all residents, staff and visitors to the home. 14th November 2005 3. 4. Date of last inspection Brief Description of the Service: The scheme consists of six houses in Baldock, five of which are detached properties and one is a semi-detached property. All are within easy walking distance of local amenities. All offer single rooms and some have assisted bathrooms. Each house has a full range of domestic facilities. New Farm has seven bedrooms, 2b Icknield Way has three bedrooms, 12 North Road has five bedrooms, 7 Clothall Road has six bedrooms, 15 Clothall Road has four bedrooms, The Rowans has five bedrooms. The aims of the scheme are to assist service users to explore facilities and integrate them into the local community and to provide an environment for service users to learn, maintain and enhance their capabilities to their limit and in accordance with their wishes. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of this inspection year (April 2006/2007), which was carried by two inspectors over a period of 8 hours. There were many positive aspects to the inspection. The information in this report is based on: • Site visits to all six houses. • Discussions with service users who live in the different houses. • Evaluation of service user questionnaires • Monthly provider reports and telephone contacts with the home since the last inspection in November 2005. Documentation checked included a sample of service users’ care plans including behaviour management guidelines, records of accidents and incidents, fridge/freezer temperature records, medication records, and the complaints procedure. A tour of each house was completed. The service users appeared pleased and satisfied with the current service. This was particularly well articulated by the service users at Ickneild way who are very able. The discussions highlighted the range and different complexities of the people living in the scheme. What the service does well: What has improved since the last inspection? Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 6 The requirements from the previous inspection have been met. There is a new management team in place, which appears committed to improving and developing the service. A format has been introduced to care planning, which is in the process of being implemented in all houses. Some further work is required with auditing care plans to ensure all service users do have a current up to date plan. The service user guide must also be completed for each house. 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. The summary of this inspection report can be made available in other formats on request. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 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 Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Sufficient information about the aims of the home, and the service to be provided is available to prospective and current service users. The pre-admission assessments format has been updated. EVIDENCE: An updated Statement of Purpose was seen as part of the inspection. All current and prospective service users are provided with a copy. The Statement contains basic information about the different homes but due to the size of the scheme, and difference in the different houses a service user guide should be completed with information about each house. Service users would then be able to make an informed choice about if they would like to live in the home that was assessed as being able to meet their need. Work has started on a user- friendly service users guide but the work is incomplete. The manager of the project currently completes an assessment for all new referrals prior to admission. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Personal support is offered to service users in a sensitive and unobtrusive manner, by staff that knows and recognise individuals needs. Care plans were in place for most service users, but not all. Service users are wherever possible being involved in the process of planning and delivery of their care, and are encouraged to fully participate in decisions that affect their lives. This is difficult for some users and outside advocacy would be beneficial. Risk assessments seen during the inspection had been updated to reflect recent developments in service users care needs. EVIDENCE: Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 10 All houses were visited as part of the inspection process, and a random sample of care plans, risk assessments and daily recordings were looked at. Two care plans initially requested at the Rowans were not available. The two other care plans looked at were good. Both contained detailed information on the service users preferences, and preferred way of doing things i.e. try to encourage the person to eat in a certain way. The service is working hard to standardize care plans, but this is a difficult task as the service provides support to a wide range of people; from people who require very little support to others with high complex needs. Communication between staff (New Farm Road) was mutually respectful, upbeat and positive. On several occasions during the inspection service users were observed receiving individual support, one young person was anxious to have a cup of tea. The member of staff reassured the person, and assisted them in a clear but caring manner. Behaviour plans at New farm were viewed. This part of the service supports people with high needs. The samples looked at provided clear guidelines for managing behaviour, and this appears to enable staff to provide a consistent approach. The two care plans looked at were clear and precise. No.7 Clothall Road had several care plans that were dated, 2004. It was unclear if they had been reviewed. One care plan stated that a person should not have chocolate cereal, but did not give the reason. Several risk assessments were dated 2003. If information is current, and there has been no change since 2003, then the service must demonstrate that they have looked at the care plan, and reviewed it. An audit of care plans is required by the management team to ensure that every service user has an up to date care plan, which clearly identifies individual needs and how the service will support each person. Having a format is a start but unfortunately does not mean it is necessary completed to a good standard in all cases. The service needs to evidence that care plans are updated and reviewed on a regular basis. There appears to be very limited advocacy input in some houses. In some cases there is no information of other people being actively involved in service users lives on file. Some service users do have regular contact with their families (New Farm). Several more able service users are involved in advocacy groups outside of the project. However there is limited advocacy input at the Rowans where service users have limited communication, and staff appear to make decisions for residents on what they should/could do on a daily basis. The scheme should look into outside advocacy being actively involved in the project. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 11 Most residents do attend day centres or are involved in regular structured activities, which is a credit to the service with such a range of people with different needs. There is also a key worker system in place, which ensures individual time and space, with someone residents know well. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,and 17. Quality in this outcome area is ( good) This judgement has been made using available evidence including a visit to this service. The opportunity for personal development is provided. Service users are encouraged and enabled to access a range of appropriate social, leisure and educational activities within the community and to maintain and develop personal and family relationships wherever possible. The service users rights and responsibilities are recognised in their daily lives. The service users enjoy a healthy diet and enjoy their meals and mealtimes. EVIDENCE: Talking to service users and staff during the inspection provided ample evidence of the participation by service users in a varied range of individually appropriate activities within the local community. Risk assessments for Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 13 individual activities where there were concerns had been completed. Service users family and friends details were indicated on some files seen. Contacts were recorded in some houses but not all. Evidence was available in some care plans seen, but information was limited in others. Most service users attend a day centre, or some form of activity outside of the home three to four days per week. All service users have at least one day off per week in order to attend to their personal tasks including washing, cleaning their rooms, and personal clothes shopping, this is usually spent with their key worker wherever possible and often includes lunch out. Staff and service users are involved in the preparation of food together. Dependent on the choice of the day and how complicated it is to cook meant how much the service users were involved. Much of the food was freshly cooked and this was a very positive system allowing everyone to do as little or as much as they were able. Snacks and drinks were available throughout the day, and there appeared to be no restrictions. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Both health care and personal support is provided in a manner preferred by the individual service user. Individual needs, choices and preferences were recorded on same of the care plans. The standard of medication practice is satisfactory. The medication cabinet at N0.7 Clothall Road needs to be re-located. EVIDENCE: Service users are supported where necessary with all aspects of their physical and emotional health, and receive adequate and appropriate input from specialists such as community nurses, consultants, GP, dentists, opticians and dieticians. Information and advice provided, was adequately monitored, and recorded in most of the contact sheets seen. Several care plans seen had been updated to allow for changing needs. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 15 There had been a medication error made by a bank member of staff working at N0.7 Clothall Road. The correct procedure had been followed to check the safety of the service user after the incident, and no further errors were found when checking administration of medication in the other houses. The medication cupboard at N0.7 is situated in the office, which houses laundry equipment. When the tumble drier is in use the temperature exceeds 25 degrees, and therefore medication is not stored in accordance with manufacturers instructions. The cabinet needs to be re located to a more suitable location. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Service users and their relatives can be confident that complaints will be listened to, taken seriously and acted upon; and their legal rights are protected. The residents are protected from abuse. EVIDENCE: An adequate company complaints procedure is in place. Staff spoken to had basic awareness of the whistle blowing policy, and this is part of the induction programme. Protection of vulnerable adults training is offered as part of Granta’s in house training. Several service users were asked if they knew how to complain and both said they would tell ‘the manager’ or their key worker. The current complaints procedure would benefit from being produced in a more user- friendly format, possible pictorials would assist the reader with greater understanding. A sample of four service users financial records was checked during the inspection. The account number should be removed from the bank statement from the service user living at Clothall Road. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,28 and 30 Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. There are six houses within the project and most of the requirements from the previous inspection relating to the environment have been met. Some continued work is required in some houses. EVIDENCE: The six properties are very different i.e. The Rowans is a relatively new property whereas New Farm is an old renovated property. Therefore, without considerable monitoring, recording and planning there will always be outstanding work required. The following feedback was provided to the registered manager with regard to the current accommodation provided. • The dishwasher in No. 15 Clothall Road is broken and requires repair. DS0000019278.V319950.R01.S.doc Version 5.2 Page 18 Baldock Core & Cluster • The service users also appear to have high personal care needs and no separate washing or toilet facilities are available to staff sleeping in at N0.15. This is difficult due to the limitations within the property but needs to be addressed. This is similar to 2b Ickneid Way but does not pose the same levels of risk because the service users are more able and do not soil the facilities. At no.7 Clothall Road the office area is also used as a laundry. Staff are therefore at risk of sitting next to soiled laundry. As an interim measure the manager has been requested to complete a risk assessment with guidance to staff on minimising the possible risk of infection. (Re the above two requirements) The medication cupboard at N0.7 is situated in the office, which also houses laundry equipment. When the tumble drier is in use the temperature exceeds 25 degrees, and therefore medication is not stored in accordance with manufacturers instructions. The cabinet needs to be relocated to a more suitable location. The bathroom at N0.7 is dated, and consideration should be given to renewel as part of maintenance plan. Front and back gardens at NO.7 should be maintained to allow ease of use and access. Both bathroom floors at North Road require new flooring, due poor condition. It is recommended that the office area and notice boards at New Farm be relocated to ensure a homely environment is present throughout the property. The back garden at 1b Ickneild Way could be a harzous to service users and requires attention. • • • • • • • • Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Adequate numbers of experienced and competent support workers are provided who are appropriately trained to meet the service users’ needs. The home operates a robust recruitment process which should provide confidence and protection to service users. Evidence of some Staff being regularly supervised was in place, but this was not consistent throughout the project. EVIDENCE: The files of two new employees were inspected. They contained all the appropriate security and identity checks including Criminal Records Bureau checks and two up to date references. Staff training within the service appears to be good. All staff at Clothall Road had completed N.V.Q training and generally throughout the project this had Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 20 been given priority. Staff said that they generally felt well supported by the senior staff based at individual homes, and also the senior management team based at the ‘Cloisters’. However evidence of regular supervision was not in place in several of the individual houses. Some staff had met for appraisals but that was all that could be evidenced. Team meetings do appear to have improved, particularly in recent months. The service employs a large number of staff working with varied, sometimes challenging people and it is important that the management team ensure staff are supervised on a regular basis. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. The policies and procedures relating to recruitment meet the requirements of the National Minimum Standards, and care homes regulations. The manager has now registered with the C.S.C.I. A new management team is now in place. The home has a full range of policies and procedures that safeguard service users’ interests. However they are not always fully implemented i.e. care plan documentation needs streamlining and more consistent updating in some houses but not all. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home has a new management team, which is starting to make some very positive changes to ensure the day-to-day functioning of the service is effective. Since the previous inspection in November 2005 requirements with regard to the fitting of dishwashers to improve infection control has been completed. Unfortunately, the dishwasher in No. 15 Clothall Road was broken and required repair. The service users also appear to have high personal care needs and no separate washing or toilet facilities are available to staff sleeping in. This is difficult due to the limitations within the property but needs to be addressed. This is similar to 2b Ickneid Way but does not pose the same levels of risk because the service users are more able and do not appear to soil the toilets etc. At no.7 Clothall Road the office is also a laundry. Staff are therefore sitting next to possible soiled laundry. The registered manager must review the facilities at N0.7 and N0.15 Clothall Road, and as an interim measure a risk assessment should be completed with guidance to staff on minimising the possible risk of infection. The registered manager must evidence that continued repair and maintance is monitored and recorded and that work is not outstanding over lengthy periods of time. Work has begun on developing an individual service users guide for each part of the service. Only one was available at inspection. Because the houses are so different and the people living in the homes again having variable needs this is very important. Whilst acknowledging the service does allow an assessment visit to a specific house this would not allow the service user to look at the size of property or the level of support offered. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 23 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 X 4 X 5 X 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 2 25 X 26 X 27 2 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The registered manager must ensure that all service users have a current, up to date care plan that is regularly reviewed (An audit is required to ensure accuracy and consistency in each house.) Involvement of advocacy services within the scheme for those who have limited networks, and difficulty in making choices should occur. The scheme must have a planned maintenance and renewal programme, and records must be kept to evidence the work that has been completed in each house. Timescale for action 31/01/07 2. YA7 12(2) 31/03/07 3. YA24 23(2)(d) 31/01/07 4. YA20 13 (2) The medication cabinet at 31/01/07 N0.7 must be relocated to a more suitable location. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 25 5. YA24 23 (2) (h) 6. YA27 23(2) (b) The communal space provided for service users must be homely and comfortable (New Farm Rd, notice boards and office area needs to be reviewed) The bathroom flooring at North Road must be replaced. The registered manager must ensure that the dishwasher at NO.15 Clothall Road is repaired and has hot water at an appropriate temperature to destroy bacteria. The external grounds must be kept tidy, safe and accessible for service users to use. (1b Ickneild Way and No.7 Clothall Road) Washing and toilet facilities for staff use when sleeping in must be reviewed. (No.15) The office space at NO.7 should not also be used as a laundry. (Both related to infection control). All staff must have regular recorded supervision meetings at least 6 times per year including an annual appraisal. The manager must ensure that where risks have been identified a full risk assessment is completed to try and reduce them and those identified must be DS0000019278.V319950.R01.S.doc 01/04/07 31/01/07 7. YA42 13 (3)& 13 (4) (a) 31/12/06 8. YA28 23(2) (b) 31/03/07 9. YA30 23(2)(c) 31/07/07 10. YA36 18 (2) 01/01/07 11. YA30 13 (4) 01/01/07 Baldock Core & Cluster Version 5.2 Page 26 reviewed. (Infection control guidance for staff as interim measure, NO.7 & 15). 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. Refer to Standard YA23 YA1 Good Practice Recommendations The service users financial details should be protected (Clothall Road). The registered manager should make available a user friendly Service User Guide, which is individualised for each home, as they provide different levels of support. Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hertfordshire Area Office CPC1 Capital Park Fulbourn Cambridge National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Baldock Core & Cluster DS0000019278.V319950.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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