Inspection on 10/11/06 for Bishops Lodge

This inspection was carried out on 10th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bishops Lodge 10/11/08

Bishops Lodge 17/11/05

Bishops Lodge 25/04/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Bishops Lodge 19 Fearon Road Hastings East Sussex TN34 2DL Lead Inspector Caroline Johnson Key Unannounced Inspection 10th November 2006 10:00 Bishops Lodge DS0000061586.V317499.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 Bishops Lodge DS0000061586.V317499.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. Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bishops Lodge Address 19 Fearon Road Hastings East Sussex TN34 2DL 01424 421684 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) gaylenewdirections@tiscali.co.uk New Directions (Hastings) Ltd Mrs Amanda Elizabeth Jane Gates Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is five (5) Service users must be aged between eighteen (18) and sixty-five (65) years on admission Service users with a learning disability only to be accommodated Service users with Prader Willi Syndrome may be accommodated Date of last inspection 17th November 2005 Brief Description of the Service: The home is situated in a detached Victorian house on the outskirts of Hastings. It is situated close to local shops, a local park and bus routes. Ore railway station is about a mile away. The home is registered to provide accommodation for five younger adults with a learning disability, predominantly those with Prader-Willi syndrome. At the rear of the home there is a garden, which slopes up away from the house, and decking has provided areas to sit. There is a building at the rear, which is used to provide an in-house day care centre. Accommodation is on two floors. There is adequate communal space and each service user has a single bedroom. Four of the bedrooms have ensuite facilities and the fifth has the use of a bathroom nearby. There are parking spaces to the front of the home. The fees for the service range from £1,451.46 to £1,507.37 each week. Additional charges are made for hairdressing, toiletries, magazines and papers. Inspection reports are made available at the home and reference to the availability of reports is also included in the home’s statement of purpose. Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process a site visit was carried out on 10 November 2006. The visit lasted from 10.00am until 5.00pm. During the visit there was an opportunity to meet with all the residents of the home, with the manager and with one member of staff in private and with two other staff generally during the course of their duties. One of the directors was also in the home for part of the inspection and she was also present when feedback was given to the manager. A wide range of documentation was examined including preadmission documentation held in relation to one resident, three care plans, staff recruitment and training records, records of incidents, menus, medication, health and safety and minutes of staff and residents’ meetings. Another part of the inspection process was to contact two of the relatives for their feedback on the quality of the care provided in the home. Comments received included ‘staff do a lot of good, they are really nice’ and that their relative is being ‘well cared for’. Another relative stated that the ‘staff are extremely hospitable, they saved their relative’s life and that ‘they manage difficult behaviours well’. One of the relatives stated that they would like to have more contact with the home via telephone and another stated that they would like reviews to be held more regularly. The manager confirmed that a review has been arranged for this resident to be held in January 2007. What the service does well: What has improved since the last inspection? The manager has completed the Registered Manager’s Award and NVQ level 4. A requirement made at the last inspection to update the home’s complaint procedure and the statement of purpose to advise that the Commission can be contacted at any stage of the complaint process has been addressed. All handwritten entries on the MAR (medication administration records) charts are dated and signed and an explanation is given. Static soap dispensers are now Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 Page 6 provided in all bathrooms as was required at the last inspection. The home remains committed to training staff to complete NVQ (National vocational qualification) at either level 2 or 3, four staff are currently studying for the qualification and on completion more of the staff team will enrol on the course. 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. Bishops Lodge DS0000061586.V317499.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 Bishops Lodge DS0000061586.V317499.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): Standards 1,2 - Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. There home provides detailed information to prospective residents and their relatives. They are also good at ensuring that they carry out a detailed assessment of prospective residents’ needs prior to making a decision about providing accommodation. EVIDENCE: The statement of purpose clearly describes the service and its aims and objectives. It includes information obtained from satisfaction questionnaires about the views of relatives and visitors to the home. The views of residents and staff are yet to be included. The terms and conditions of residence are attached to the service user guide and there is a pictorial complaint procedure. Within the terms and conditions of residence there is information about how inspection reports are made available. Pre admission documentation was seen in relation to one resident. There was a very comprehensive assessment in place and the home had obtained a wealth of information form both Social Services and resident’s previous placement. Bishops Lodge DS0000061586.V317499.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): Standards 6,7,9 - Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Care planning is good and staff are given very detailed information about each of the resident’s abilities and needs. Having more specific goals and more explicit action points on how to achieve these goals would enhance what is already a good care planning system. The use of daily records to record progress with goals would also assist this. EVIDENCE: Three care plans were examined. Each included a very detailed assessment of each of the residents’ abilities and needs and advice about the action to be taken by staff to ensure that residents’ needs could be met. There are numerous risk assessments in place and detailed advice about behaviour management. There were goals highlighted in each of the care plans. Many of the goals were very broad and the action to be taken by staff was not very explicit. For example, an aim for one resident was to ‘cut down to the bare minimum with cigarettes’. How this was to be achieved included ‘ with help and support from staff’. There was no indication of how many cigarettes the Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 Page 10 resident smoked each day and more specifically what agreements had been made with the resident about how staff were going to support them to reduce the number of cigarettes smoked. In another care plan a goal was for the resident to find work in a particular setting and the action required by staff stated ‘enquiries currently taking place’. No specific information was included about what type of enquires or any research done in this area. The manager advised that a lot of work had been carried out in respect of each goal and that the action taken is generally discussed at reviews. She agreed that regularly recording progress would build upon and improve the care planning system. The home has started encouraging residents to sign risk assessments and this will also be introduced for goal planning. Residents are encouraged to make decisions in a variety of ways such as the clothes they wear, the food they eat and the activities that they participate in. Drinks can be made at any time of the day and all of the residents are able to help themselves to this facility independently. Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15,16,17 - Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. All of the residents take part in activities that are rewarding and stimulating and this is one of the homes strengths. The home is good at ensuring that the residents remain very active and this coupled with good weight management promotes good wellbeing and self esteem. EVIDENCE: Each of the residents has a programme of activities in place that are geared towards meeting their individual needs. Some of the residents have work placements, some attend college and the majority attend the in-house day centre either based at their home or in one of the sister homes. From the day centres residents are supported to attend various community-based activities such as swimming, badminton, trampoline, horse riding, gym and pottery. Residents spoken with stated that they enjoy the variety of activities. A short amount of time was spent in the day centre where three of the residents were Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 Page 12 busy being creative. Examples of the work they produce was displayed around the room and the staff member that supports the residents also keeps a record of all activities undertaken and each of the resident’s level of participation. The residents were very relaxed in their surroundings and enjoyed chatting about what they do in their spare time. Residents’ meetings are held regularly and everyone is encouraged to share their views. Minutes of the outcome of the meetings are displayed on the residents’ notice board. The residents stated that they enjoy going to the pub in the evenings and that they regularly socialise with the residents of the other homes within the company. Some of the residents have friendships/relationships with people who do not live in the home. They are able to entertain their friends in their home and to visit their friends. Families are encouraged to visit and those spoken with stated that they re always made to feel welcome in the home. There is a four-week menu in place, which is varied and well balanced. The menus are reviewed regularly and discussed with the residents. The meal provided on the day of inspection was nutritious and well balanced. The manager advised that all meals are calorie counted on a daily basis. Occasionally residents enjoy what they refer to as a ‘naughty meal’. That means they have a meal that is higher in calories than usual but it also means that the following meal might then be lower in calories. Two of the staff team have a background in catering, which is an added bonus when planning and cooking special meals. Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19,20 - Quality in this outcome area is (excellent) This judgement has been made using available evidence including a visit to this service. The home is very good at ensuring that the healthcare needs of the residents are met. The success achieved in promoting healthy lifestyles through weight management and in ensuring that medications are reviewed regularly has substantially improved the quality of the lives of some of the residents. EVIDENCE: One resident is given his medication on a daily basis which he then has responsibility for taking. A risk assessment has been carried out and the procedure works well in practice. When he returns the empty box the following day staff sign that he has done so but not that they have witnessed him taking the medication. The procedure for signing needs to be explained more clearly in the written risk assessment. Medication is stored securely and record keeping is good. A returns book is kept to record all medication returned to the home’s pharmacy. All of the senior staff received training last year on medication. The manager advised Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 Page 14 that she has found a suitable training course for staff to attend this year and that this would be arranged. Residents’ weights are monitored weekly and there is a comment section beside the recorded weight to explain why weights might have increased or reduced. Residents are supported to attend a wide range of healthcare appointments including chiropody and opticians. One of the directors has recently completed a course on ‘Nutrition in Care’ and training on this subject will be cascaded to all staff in the coming months. Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22,23 - Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. There are good procedures in place to ensure that anyone wishing to make a complaint can do so. EVIDENCE: The home’s complaint procedure is in written and pictorial format. As required at the last inspection information is now included about how to contact the Commission at any stage of the complaint process. There were no complaints recorded since the last inspection. A complaints/suggestions box is located in the hallway so that anyone wishing to make a complaint, compliment or suggestion for change can do so. The manager advised that this box is checked on a regular basis. Details of all incidents that occur in the home are recorded. Following incidents where it is assessed as necessary, behaviour guidelines are reviewed and if necessary risk assessments are put in place. Since the last inspection there have been no complaints or allegations of adult protection sent to the Commission in relation to the home. Staff have had training on the protection of vulnerable adults. Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,28,30 - Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home is well maintained and decorated to a very good standard. The cleaning rotas ensure that the home is kept clean and that the tasks are divided equally. EVIDENCE: A full tour of the home was not conducted on this occasion. However, three of the residents took the inspector to see their rooms. The rooms were well decorated and had been personalised by the residents. One resident has a pet in his room and he stated that it is his responsibility to clean the cage on a regular basis. Bedrooms are considered personal space and as such it is down to the residents to arrange and keep as they choose. However, each of the residents has one day a week when they clean their room and if needed staff support residents with this task. A record is kept that this has happened. There is a very large lounge/dining room, which is well decorated. Since the last inspection the office has moved from upstairs to downstairs. The Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 Page 17 conservatory has been divided into two. One part is now the office and the second part is a smoking area for residents. Residents play a part in ensuring the cleanliness of their home but only residents that smoke have a responsibility for cleaning the smoking area. In relation to fire safety records showed that alarms are checked weekly and lights monthly. Fire drills are held at regular intervals and records showed that the outcome of each drill is clearly evaluated. The manager confirmed that a fire risk assessment had been carried out two days prior to the inspection so the home are now awaiting the report. Fire extinguishers were also serviced at that time. All areas of the home seen during the inspection were clean and there were no unpleasant odours. Each of the residents has responsibility for doing their own laundry and there is an agreement between all the residents that all laundry should be finished by eight in the evening. Bishops Lodge DS0000061586.V317499.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34,35,36 - Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. There are good training opportunities available for staff and staff feel well supported and valued. Recruitment procedures are thorough ensuring that new staff are vetted appropriately before starting to work in the home. EVIDENCE: The rota shows that there are two care staff on duty each day. The morning shift is from 7.00am until 3.00pm and the afternoon shift is from 2.00pm until 10.00pm. In addition there is a day services worker employed to work 9.00am till 5.00pm Monday to Friday. Staff stated that having the handover period ensures that there is good communication between shifts. Four of the staff team are currently working towards a NVQ (National Vocational Qualification). The manager advised that as staff complete the course other care staff would then be enrolled to commence studying for the qualification. Staff spoken with over the course of the inspection had attended courses on prader willi syndrome, scip, behaviour management, health and safety, first aid, adult protection, infection control and basic food hygiene. Recruitment records were seen in relation to one member of staff. The home had been thorough in ensuring that there was a detailed application form and Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 Page 19 two references had been obtained. The pova first list had been checked but as the CRB had not yet been obtained the staff member was still working under supervision. The manager reported that she meets with the new staff member every day to check that they are settling in well. There is a three-month probationary period and this can be extended depending on the particular needs of each new staff member. The home has recently introduced the new (CIS) Common Induction Standards for new staff. The manager reported that she aims to provide staff supervision monthly. Staff confirmed that they receive regular supervision and that they find the supervisions very helpful. Bishops Lodge DS0000061586.V317499.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,38,39,42 - Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The manager is very experienced and well qualified to run the home effectively. The regular audits carried out by the home ensure that there is a system of continually reviewing and building upon the quality of the care provided. EVIDENCE: The registered manager has completed the RMA (Registered Manager’s Award). She has also completed NVQ level four and is currently awaiting her certificate. She advised that she is hoping to start studying for the A1 Assessor’s course in January. Staff spoken with described the manager ‘as supportive and very helpful’ and that ‘she listens to your ideas’. Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 Page 21 Staff meetings are held regularly and minutes of the last meeting held were detailed ensuring that all staff were given clear advice of changes in care practices. Quality assurance systems include sending satisfaction questionnaires to residents, their relatives and visitors and to staff. Questionnaires had been distributed recently so the home was still waiting on all the responses. She advised that she would be collating all the responses and providing overall feedback to everyone on the outcome. It was noted that the staff questionnaires generally require a yes /no answer and that very few staff record any comments. The manager agreed that she would review the layout of the form and encourage staff to provide comments. In addition to questionnaires a number of audits are carried out in the home to measure quality. One of the audits includes medication and this is carried out on a monthly basis. As part of the inspection process contact was also made with the relatives of two of the residents. Comments received were very positive including the ‘staff do a lot of good, they are really nice’ and that their relative is being ‘well cared for’. Another relative stated that the ‘staff are extremely hospitable, they saved their relative’s life and that ‘they manage difficult behaviours well’. One of the relatives stated that they would like to have more contact with the home via telephone and another stated that they would like to see reviews held more regularly. The manager has since confirmed that a review has been arranged to be held in January 2007. Prior to the inspection comment cards had been sent to the home for distribution to the residents. Five responses had been received prior to the site visit. Three were wholly positive with residents stating that they were given lots of information prior to being admitted to the home, saying that they make decisions and that staff are supportive. One comment card was part positive and part negative although no written comments were made. The last comment card was very negative and the resident had written that he wanted to be moved from the home. The manager advised that the resident had informed her that he had made the comments after a difficult day and that he hadn’t meant what he had said. Time was spent in private with this resident during the day of inspection and the resident confirmed that he is happy in the home, he is settled, staff are supportive and he likes his room and fellow residents. Portable appliance testing is carried out annually and the home was tested for Legionella last month. There is a very detailed health and safety assessment for the building with some checks being made on a weekly and some on a monthly basis. As required at the last inspection static soap dispensers are now provided in the bathroom areas. Bishops Lodge DS0000061586.V317499.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 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 X X 3 X Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1) Requirement Goals agreed with individual residents must be specific and the action required by staff to assist residents to meet the goals explicit. Timescale for action 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. YA39 Refer to Standard YA1 YA20 Good Practice Recommendations The home’s service user guide should include information about the views of the residents that live in the home. The home should amend the risk assessment in place in relation the signing arrangements for one resident’s medication. Following discussion with residents and relatives the home should agree in each case how to ensure good communication is maintained. Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Bishops Lodge DS0000061586.V317499.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!