Inspection on 25/07/06 for Bartlett Close 1

This inspection was carried out on 25th July 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bartlett Close 1 23/02/09

Bartlett Close 1 31/10/07

Bartlett Close 1 09/01/07

Bartlett Close 1 06/10/05

Bartlett Close 1 21/07/05

Bartlett Close 1 21/02/05

Bartlett Close 1 13/05/04

Bartlett Close 1 09/03/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 1 Bartlett Close Witney Oxfordshire OX28 6FD Lead Inspector Lilian Mackay Unannounced Inspection 25th July 2006 09:30 1 Bartlett Close DS0000013063.V305023.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 1 Bartlett Close DS0000013063.V305023.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. 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Bartlett Close Address Witney Oxfordshire OX28 6FD 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) 01993 709646 01993 709659 www.macintyrecharity.org MacIntyre Care Pauline Buckingham Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 1 Bartlett Close is home to four adults with learning and some physical disabilities close to the centre of Witney, a market town in West Oxfordshire. The home is managed by MacIntyre. The building is modern and purpose built to meet the needs of people with physical disabilities. Care is provided by a staff team, which aims to enable the service users to lead active lives and pursue their own interests in and out of the home. 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced “key” inspection’ which took place over two days where the inspector inspects the service against all the key standards. The inspector arrived at the service at 2pm one day and was in the service for 5 hours, and spent another two hours another evening at the service. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that the CSCI has received about the service since the last inspection. The inspector observed interactions with the four residents and staff, spent time examining policies and procedures, residents’ and staff records and other documentation, spoke to staff and obtained feedback by means of questionnaires sent to staff and professionals with knowledge of the service. The inspector looked at how well the service was meeting the standards set by the government, and has in this report made judgements about the standard of the service. The purpose of this inspection was to see how the home is meeting the National Minimum Standards for care homes for adults 18-65. Management contributed greatly to this inspection by sending the CSCI full and timely pre – inspection information including a self-audit against the National Minimum Standards for care homes for adults 18 - 65. The manager is leaving the home in October. Feedback was also obtained from questionnaires sent to relatives/visitors and GPs with knowledge of the home. Feedback from GPs was positive and indicated overall satisfaction with the standard of care provided by the home. Feedback from relatives and visitors was also very positive. They commended the home for making them feel welcome in the home at any time, and for always having sufficient staff on duty. Most were unaware of the home’s complaints procedure and only one had had to make a complaint. All were satisfied with the overall care, which the agency provides. Their feedback indicates that how to get a copy of the CSCI inspection reports on the agency needs highlighting. Their comments included - “We would like more activities for X. But sometimes it’s difficult as to amount of staff”. Comments from staff included ”I enjoy my job. I love it here. It’s like coming home”. “It’s a lovely project. The residents are fulfilled in as much as we possibly can. There is a very stable staff team. We’ve only recently had to start using agency staff.” 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 6 The inspector would like to thank the staff, residents, clients, professional and relatives/visitors who contributed to this inspection for their courtesy, assistance and hospitality. What the service does well: 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. 1 Bartlett Close DS0000013063.V305023.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 1 Bartlett Close DS0000013063.V305023.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Every resident has had a full assessment of his or her care needs prior to being admitted to the home. The home meets residents’ specialist needs well, including learning disabilities and communication difficulties. License agreements are drawn up with each resident. EVIDENCE: The Service Users’ Guide needs updating to refer to the CSCI and not the previous regulators. All four residents have lived at Bartlett Close for a number of years and no new individuals have been admitted since 1999. The inspector could therefore not look at any new assessments. However, a staff member told the inspector that if a new resident were to be admitted that he/she would have a full assessment. Specialist needs are recorded in care plans. A nurse provides specialist training for staff in health care tasks such as stoma care and this is updated annually. An excellent illustrated presentation of such training was seen. Residents communicate their needs in a variety of ways both verbal and nonverbal, and staff are skilled at interpreting and acting upon these. 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 9 There is a MacIntyre Housing Association License Agreement, which is in Makaton for residents’ benefit. 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 10 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): 6,7,9,10 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a service tailored to the individual needs of residents as identified in their personal care plans [PCPs]. Regular reviews of personal care plans are carried out and these are clearly documented. Residents’ individual needs and choices are well provided for. Staff assist residents in making decisions and act upon their choices. Risk assessments are carried out, reviewed and documented and these are effective in promoting residents’ independence. EVIDENCE: Care plans are drawn up with the involvement of the residents family or representative. Each resident has an annual review of this involving his/her family and care manager. These identify any new needs and these are discussed and action agreed. Care plans are updated within the home on a monthly basis and indicate that residents’ choices are acted upon by staff. 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 11 Residents’ individual personal plans reflect the way each resident wants or needs to lead his or her own life. Staff seek residents views and respect the choices they make. Staff communicate with each resident in an individual manner based upon their knowledge of and relationship with each resident. Residents benefits are paid directly into their own personal accounts. Staff, guided by appropriate procedures, assist residents with their money. A large variety of risk assessments were seen for the individual activities residents have chosen to do. These were seen to be reviewed regularly. Residents personal records are stored securely and their finances are handled carefully and are very well accounted for. There is a confidentiality policy and staff are trained to respect confidentiality as part of induction and on-going training. 1 Bartlett Close DS0000013063.V305023.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents participate in a range of developmental activities and are involved in local community life. Residents are given the opportunity to pursue their own interests and lifestyle. They have appropriate personal and family relationships and are encouraged to accept responsibility in their daily lives. The lifestyle of residents provides adequate stimulation and social inclusion. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. EVIDENCE: Each resident has a daily activity plan based on his or her wishes and needs, and they are all encouraged to practice skills for daily living. Residents attend college for computing. Residents also enjoy other local amenities including the library, swimming and hydrotherapy pools, riding, bowling, music and dance, keep fit, public 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 13 transport, the shops, leisure centres and going for meals out. All residents go on holiday and on day trips out. Staff would prefer a bigger vehicle equipped with a ramp and a hoist, which could accommodate wheelchair users. A staff member reported that the van was due to be replaced in 2007. A staff member suggested hiring a second vehicle rather than having a vehicle in Aylesbury. Within the home residents enjoy baking and cooking, arts and crafts, music and singing, sensory massage and reflexology, doing puzzles and games, listening to CDs and watching DVDs, reading magazines, letter writing, using the paddling pool and the garden swing. Residents have weekly meetings and do the weekly shopping. Residents are encouraged to practice daily living skills. A record is kept of visitors to the home. There are two telephones for residents’ use, one of which is a mobile. Visitors’/relatives’ feedback indicated that they are made to feel welcome at the home. All bedroom doors are lockable. Residents are encouraged to respect the time and space of others and the privacy of bedrooms. The menu plans examined, whilst recording individual lunch choices well, did not record either individual choice for breakfast, suppers or snacks and contained vague references such as cooked brunch or take away. This does not meet the standards required by the Regulations. This was a statutory requirement at the homes last inspection to be complied with by 06/10/05. The menu plans examined did not evidence that residents are having an adequate daily intake of fresh fruit and vegetables. Liquidised diets are provided when required. 1 Bartlett Close DS0000013063.V305023.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ physical and mental health needs are met through a range of community-based services. Competent staff administer medication and residents are provided with good personal support and healthcare. EVIDENCE: When listening devices are required in residents’ bedrooms for monitoring the occurrence of seizures, it is recommended that this be well documented in a restriction of liberty care plan within the main care plan. It is recommended that these be reviewed six monthly with a relative and/or a professional outside the home. It is also recommended that formal, written guidance be made available to ensure all staff are aware of the correct usage of such devices. Staff were observed providing support in a discrete and respectful way that also recognised individual choices. Residents belongings and behaviours were seen to be respected and recognised by the staff on duty. Residents had aids to assist them with their daily lives. Residents have varying levels of healthcare needs. These were being supported and met by staff. Each resident is registered with the local GP and dental practice and a chiropodist visits the home. GPs feedback indicated that staff at 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 15 the home communicate clearly with GPs, that medication is appropriately managed, that staff have a clear understanding of the care needs of residents and that they are satisfied with the overall care provided to residents in the home. During the inspection, medication was found to be appropriately stored well organised and for the most part well documented. Staff are commended for improvements in this area since the last inspection. Records in relation to the review and administration of medication and return of unused medication to the pharmacy were satisfactory. All residents are supported with their medication by staff. Overall the inspector found the home to be providing a high level of care in a homely and relaxed environment. There were good relationships between the residents and staff on duty, with staff being responsive to residents’ needs in a respectful manner. The overall impression that the inspector gained was that the residents were being well supported by staff who treated them with respect. There are generally good systems in place for the management of medication and these are monitored monthly. Staff receive training in medication administration procedures and the recording of this and they are required to demonstrate competence twice before being designated to administer this. Whilst staff generally give medication in accordance with the instructions from the GP an exception to this was seen where a gap was left on the medication administration record on one occasion when a cream was applied. GPs formally approve the administration of homely remedies. It is recommended that time limited preparations are always dated on opening Residents have 6 monthly dental checks and chiropody 6-8wkly. 1 Bartlett Close DS0000013063.V305023.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst the complaints procedure is compliant with the Regulations and is accessible to those wishing to use it, not all concerns, allegations and complaints are reponded to in time. Whilst staff have an understanding of issues around adult protection, management do not always notify the CSCI of allegations made against staff as required by the legislation. EVIDENCE: The complaints procedure is displayed on the notice board and is available in Rebus for residents’ benefit. The home’s complaints procedure now includes the contact details of the CSCI. Four complaints were received in the last 12 months and 80 of these were responded to within 28 days. Regulation 20 requires all complainants to be informed of the action taken within 28 days. The staff member spoken to about this was able to easily locate a copy of Oxfordshire’s Multi-Agency codes of practice for the protection of vulnerable adults and was familiar with this. This is regularly reviewed and revised. An examination of staff records indicated that staff are recruited appropriately with the required checks being undertaken to protect residents. However, the CSCI were not notified of a member of staff resigning as required by Regulation 37(1)(g). Staff receive training in protecting vulnerable adults from abuse as part of induction and ongoing training. No POVA allegations were made since the last inspection. 1 Bartlett Close DS0000013063.V305023.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Home improvements are made more promptly now and the home is safe, comfortable and meets residents’ needs. The home was clean, tidy, hygienic and fresh smelling at this time. EVIDENCE: The home was purpose-built 11 years ago. It was planned with the assistance of one of the current residents, and continues to meet the needs of residents with a physical disability. A new kitchen is planned for 2007. Since the last inspection the floor covering in the hallway has been replaced with attractive wooden type flooring, kitchen tiles have been replaced and the downstairs WC and one resident’s bedroom have recently been redecorated. A movement or sensor buzzer is going to be installed to enable easier access to the front garden for residents. There are plans to convert the laundry room and to refurbish the kitchen in 2007. The home was clean, tidy, hygienic and fresh smelling at this time. 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 18 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 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff recruitment, training and development are adequate. Staff have good relationships with residents. Additional information is required to assess if staff are well trained with the skills to do the job. The required ratio of staff trained to NVQ level 2 has not been achieved within the timescale given. The number and skill mix of staff on duty is adequate, and staff are well supervised and supported. EVIDENCE: The home is now fully staffed. Residents assist in staff recruitment by completing questionnaires. There is a minimum of two staff on duty throughout the day. The home employs eight staff including one casual member of staff. Two staff have left since the last inspection. Staff receive adequate fire and first aid training. The staff member asked did not know who the designated first aider was for that shift. This should be highlighted to staff. Whilst it is commendable that there is a staff training plan, the plan examined did not evidence that all staff had received abuse awareness training the previous two years or that health and safety, first aid 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 19 and food hygiene training is regularly updated or that staff receive training in infection control. At this time 62 of staff had NVQ level 2 or above. One staff member was doing the registered managers award. Staff reported receiving monthly supervision and monthly staff meetings. There is a relatively stable staff team. Whilst agency staff are used, this is not done to any great extent. 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 20 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): 37,39,42 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has undergone appropriate training. Whilst the home is adequately managed evidence was not seen of a recent Review of Quality of Care. The home’s record keeping and policies and procedures safeguard residents’ health, safety and welfare. The care and teamwork is adequate and the supporting management systems are adequate. EVIDENCE: Although a staff member confirmed that an Annual Quality Review entitled Investors in Care Assessment is carried out on the service provided, the registered manager was unable to supply the CSCI with a copy of this as required by the Regulations. One staff member said, ”I would like to have more consistency of area managers. These tend to change every nine months.” MacIntyre managers 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 21 meet monthly. A staff member spoken to about this felt adequately supported by colleagues and the organisation. Staff would like more staff training to be done locally and would like staff hours to be increased by an additional part-timer so that additional activities can be undertaken outside the home. The systems for health and safety in the home are generally good. Risk assessments in relation to various activities are in place and reviewed regularly. Residents’ health and safety is promoted by having sufficient staff on duty with scope to summon additional support as required. Health and Safety audits are completed monthly and Control of Substances Hazardous to Health [COSHH] assessments are checked weekly. The fire precautions are checked regularly, monthly fire drills are carried out and staff receive adequate fire training. 33 of the 35 relevant recommended policies and procedures are available. 21 of these were reviewed in the last three years. Accurate records are kept of the management of residents personal allowances. The manager is leaving her position in October 2006. Residents and staff are asked their opinions of the running of the home at staff meetings and there is an annual house plan for 2006. The proprietors representative carries out monthly unannounced monthly visits to the home as required. 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 22 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 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 3 X 2 X X 3 X 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 23 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 YA17 Regulation 17(2) Requirement The manager must ensure that records are kept of all meals served to residents. [06/10/05] Inform all complainants of the action to be taken, if any, within 28 days. Notify the CSCI of any allegations made against any member of staff. Evidence that staff have received the training identified. Supply a copy of the last Annual Quality Review to the CSCI. Timescale for action 31/08/06 2. 3. 4. 5. YA22 YA23 YA33 YA39 20 37[1][g] 18 24 31/08/06 31/08/06 31/08/06 31/08/06 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. 2 Refer to Standard YA1 YA17 Good Practice Recommendations Update the Service User’s Guide to refer to the CSCI. Document the use of listening devices in a restriction of liberty care plan within the main care plan and review these six monthly involving a relative and/or a professional DS0000013063.V305023.R01.S.doc Version 5.2 Page 24 1 Bartlett Close 3 YA32 outside the home. Make formal, written guidance available for staff to ensure all staff are aware of the correct usage of such devices. Ensure that 50 of staff are trained to NVQ level 2 or above as soon as possible 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 1 Bartlett Close DS0000013063.V305023.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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