Inspection on 13/12/06 for Briar House

This inspection was carried out on 13th December 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Briar House 26/11/08

Briar House 21/12/05

Briar House 12/05/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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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 Briar House Briar House 89 Povey Cross Road Hookwood Surrey RH6 0AE Lead Inspector Deavanand Ramdas Key Unannounced Inspection 13th December 2006 11:30 Briar House DS0000062117.V320260.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 Briar House DS0000062117.V320260.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. Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Briar House Address Briar House 89 Povey Cross Road Hookwood Surrey RH6 0AE 01883 731547 01883 744721 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) Cavendish care Miss Tracey Lynne Spencer Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18-45 YEARS. 21st December 2005 Date of last inspection Brief Description of the Service: Briar House is registered with the Commission for Social Care Inspection henceforth referred to as the CSCI to provide accommodation and care to six service users with a learning disability. The home is located in a residential area close to public amenities and other facilities and accommodation comprises of an office, lounge, kitchen, dining area, laundry room, bathrooms, toilets and six single bedrooms with en-suite facilities. The home has a garden which is secure and accessible and private parking is available. The range of fees charged by the home is £1550 to £2316 per week. The manager of the home is Ms. Jackie Schofield who has submitted an application for registration with the CSCI. Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a site visit as part of the key inspection process and carried out by Mr. D. Ramdas. The site visit commenced at 11:30 hrs and finished at 17:30 hrs and included a tour of the premises, interviews with staff and service users and a review of documents and records at the home. The inspector noted service users have communication difficulties and judgements were made about them based on their mood, behaviour and information given by staff. The inspector would like to thank the manager, staff, service users, relatives and a care manager for their contribution to the inspection. What the service does well: The home has a manager who provides management stability, leadership and direction to the staff team. During discussions a member of staff stated ‘‘management is very nice, very co-operative and very solid’’. Activities at the home are well planned and organised and reflect the needs of service users. During discussions a member of staff stated ‘‘there has been a lot of progress with service users and improvements in behaviour and activities’’. Meals at the home are good and offer variety and choice. The inspector noted the menu plan had input from a dietician to ensure it is adequate to meet the needs of service users. During discussions a service user with African ethnicity indicated ‘‘food is good, I like rice and stew’’. Care planning at the home is good with health action plans and person centred plans to reflect the personal care and health needs of service users. It is recorded by a relative on a comment card ‘‘I am very happy with the care my son receives at Briar House’’ and a care manager recorded ‘‘I have always had excellent service with Gresham/Cavendish Care’’ which includes Briar House. The complaints policy is good with information about complaints in a widget format (a method of communication using pictures and symbols) to make the information understandable to service users. During discussions a member of staff stated ‘‘we discuss complaints and policies at supervision’’. The home values equality and diversity and staff have value based training with person centred plans reflecting the unique needs of individual service users. One service user had a named key worker with African ethnicity to meet his communication and cultural needs and during discussions the service user indicated ‘‘staff are good, I like my key worker’’. Quality assurance at the home is good with regular Regulation 26 (monitoring visits). Further evidence confirmed the home used questionnaires to obtain feedback about the home from relatives, service users and stakeholders with a report available in the home for information. It is recorded by a relative on a comment card ‘‘there is a great deal of communication between myself and the staff at Briar House’’. Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Briar House DS0000062117.V320260.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 Briar House DS0000062117.V320260.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service user guide are good ensuring prospective service users have up to date information on which to make decisions about admission to the home. The arrangements for assessing needs are good safeguarding the welfare of prospective service users. EVIDENCE: The home had a statement of purpose and service user guide which was written in plain English, nicely presented and accessible for information. The inspector noted information in the service user guide was in a widget format (a method of communication using pictures and symbols) to make the information understandable to service users and had details about the range of fees charged by home. The manager stated service users would be admitted to the home on the basis of an assessment of needs. Further evidence confirmed the home had a policy on assessing needs and a review of records indicated an assessment and proposed care plan for prospective service users. The inspector noted the home had joint needs assessment involving social services which covered personal care, health needs and social support. Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 9 A care manager commented ‘‘I have always had excellent service with Gresham/Cavendish Care’’ which includes Briar House. Briar House DS0000062117.V320260.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning need strengthening to reflect the changing needs and aspirations of service users. Decision making at the home is good enabling service users to make decisions about their lives and assistance as needed. Risk taking is good promoting the independence of service users. EVIDENCE: The manager stated the home had individual care plans. Further evidence confirmed the home had person centred plans drawn up with the involvement of service users who had named key workers. The inspector noted care plans had management guidelines for service users likely to be aggressive and included one to one communication support. Following discussions with the manager a requirement has been made for a care plan review to be undertaken pertaining to a service user who had been involved in a safeguarding adult investigation to promote personal safety. Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 11 The home had recently introduced meetings with service users to promote decision making and participation in the home. The inspector sampled the minutes’ of meetings attended by staff and service users which included decisions about holidays recorded for action. Observations confirmed staff respected service users’ right to make decisions and one service user had a named advocate involved in promoting rights. Following discussions with the manager a recommendation has been made for the minutes of service users meetings to be in a format which is understandable to service users. The manager stated the home had a policy on risk taking and a review of records confirmed the home had written risk assessments. Further evidence confirmed risk assessments were regularly reviewed and dated and signed by staff. The inspector noted risk assessments promoted independence and agreed risks included swimming activity and the use of the homes transport to promote community access. It is recorded by a relative ‘‘I am very happy with the care my son receives at Briar House’’. Briar House DS0000062117.V320260.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): 12,13,15,16&17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for occupation are good ensuring service users participate in valued and fulfilling activities. Community links are good ensuring service users are part of the local community. Relationships are good ensuring service users maintain links with family and friends. The arrangements for daily routines are good and promote the independence of service users. Meals are good and offer variety and choice. EVIDENCE: The manager stated the home had a weekly activity programme for service users in the home. A review of records confirmed staff supported service users to access local colleges for art, drama, literacy, maths and IT skills training. Further evidence confirmed the company employed a placement officer to find Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 13 paid and voluntary work for service users and evidence confirmed one service user did voluntary work at a local charity shop to develop employment skills. The home fostered community links and a review of records confirmed service users accessed local shops, pubs, cinemas and leisure facilities to promote social inclusion. The manager stated relatives are welcomed at the home and service users are supported to maintain family links. A review of records confirmed relatives visited the home and service users went on leave to spend time with family and friends. Observations confirmed the home had private areas for service users to see relatives and visitors in private, and service users have the opportunity to make friends at the local college and social events. During discussions a member of staff stated ‘‘there has been a lot of progress with service users and improvement in behaviour and activities’’. The home had routines to promote the independence of service users and observations confirmed staff addressed service users by their preferred names and service users had unrestricted access to the home and grounds. Further evidence indicated staff knocked on doors before entering bedrooms and staff interacted with service users in the kitchen and joined in the preparation of lunch. The manager stated the home had written menu plans. A review of records confirmed menu plans offered variety and choice with healthy eating options. The inspector noted the menu plan had dietician input to ensure it is adequate to meet the nutritional needs of service users. On the day of the inspection service users had a lunch of vegetable soup, bread with butter, yogurt and hot and cold drinks available. Mealtime was relaxed and unhurried and staff supported service users appropriately using sign language to promote communication. The inspector noted service users were happy and smiling at lunch and one service user with an African ethnicity commented ‘‘he liked rice and stew’’ reflected on the menu plans. Briar House DS0000062117.V320260.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for personal support are good ensuring service users receive personal support in the way they prefer and require. The systems for health care are good ensuring service users physical and emotional needs are met. Medication management is good and promote health. EVIDENCE: The home has arrangements for personal support and a review of person centred plans confirmed written guidelines with morning and night time routines to promote privacy and independence. Further evidence confirmed a service user with an African ethnicity had a key worker from the same cultural background to meet his communication and cultural needs. During discussions the service user indicated ‘‘staff are good, I like my key worker’’. The manager stated the home had arrangements for meeting the health care needs of service users who were registered with a local GP (general practitioner) and the home had input from a psychiatrist, behaviour specialist and district nurse to meet the needs of service users. Further evidence confirmed the home had Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 15 health action plans and service users attended a well man and well woman clinic at the local GP surgery to promote health. The home has a policy on medications and the provider has notified the CSCI of the appointment of a medication officer to promote the health of service users. Further evidence confirmed the home had a service level agreement with a local chemist and the home kept a record of medications received by and returned to the pharmacist to prevent mishandling of medications. Observations confirmed the home had adequate storage of medications and medication record sheets were dated and signed by staff with a list of staff specimen signatures available for information. The manager stated homely remedies will be printed on medication record sheets and a review of records confirmed staff have training in medications. Following discussions with the manager a recommendation has been made for a recent photograph of service users to be included in the medication folder and handwritten prescriptions to be dated, signed and witnessed by a second member of staff to promote good practice. Briar House DS0000062117.V320260.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints process is good ensuring complaints information is available to service users, staff and relatives. The arrangements for protection are good safeguarding the welfare of service users. EVIDENCE: The home had a policy on complaints and information about complaints was in a widget format (a method of communication using symbols and pictures) to make the information understandable to service users. The inspector noted complaint information displayed in the hallway and a review of records confirmed no complaint was recorded about the home. During discussions a member of staff stated ‘‘we discuss complaints and policies and procedures at supervision’’. The home had a policy on safeguarding adults and a copy of the local authority (Surrey County Council) procedures on the protection of vulnerable adults. Further evidence confirmed the home had a whistle blowing policy and staff have training in safeguarding adults. A review of records confirmed one incident investigated under safeguarding adult procedures with appropriate management action taken. The inspector noted staff have training in challenging behaviour and the use of restraint to ensure physical and verbal aggression by a service user is understood and dealt with appropriately. It is Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 17 recorded in a relative comment card ‘‘there has only ever been one problem at Briar House. This is being dealt with’’. Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24&30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for the premises are good ensuring service users have a comfortable home in which to live. The systems for hygiene need strengthening to ensure the home is clean and hygienic for service users. EVIDENCE: The home’s premises are suitable for its stated purpose and are in keeping with the local community. The home has a good standard of décor with good quality furniture and fittings. On the day of the inspection the home was clean, well ventilated and free from mal odour and a review of records confirmed the home had a fire safety risk assessment and a visit from the local authority (Surrey County Council) environmental health officer with appropriate management action taken. Recent investment by the provider has improved the environment and areas of the home have been redecorated with new carpets and furnishings for the enjoyment of service users. The garden is Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 19 secure and accessible and during discussions a service user indicated ‘‘I am happy here’’. The home has a policy on infection control and a service level agreement with an approved provider for the disposal of clinical waste. Further evidence confirmed the home had a laundry room with washing machines and dryers and hand washing facilities were prominently sited. Observations confirmed staff practiced infection control measures by washing their hands regularly to prevent the spread of infection. Following discussions with the manager a requirement has been made for staff to have training in infection control to safeguard the welfare of staff and service users in the home Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. 32,34&35 This judgement has been made using available evidence including a visit to this service. The arrangements for NVQ training need strengthening to ensure service users are supported by competent and qualified staff at all times. Recruitment and vetting practices are good and safeguard the welfare of service users. The arrangements for induction need strengthening to ensure the joint needs of service users are met by appropriately trained staff at all times. EVIDENCE: The manager stated the company is committed to staff training and development and observations confirmed staff were accessible to, approachable by, and comfortable with service users. Further evidence confirmed staff have training in autism and knowledge of the specific conditions of service users including epilepsy. The inspector noted the company had an agreement with an approved provider for NVQ training and the manager confirmed two staff have NVQ with a further two staff to be enrolled on the programme. Following discussions with the manager a requirement has been made for an action plan to be completed outlining how Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 21 the home will achieve training targets to ensure service users are supported by competent and qualified staff at all times. The home has a policy on recruitment and retention of staff and staff have copies of the GSCC (General Social Care Council) code of conduct for information. Further evidence confirmed staff have recruitment files stored in a locked cabinet to promote confidentiality. A review of records indicated staff have completed application forms, written references, health questionnaires, terms and conditions, job descriptions, CRB (Criminal Record Bureau) disclosure information and a recent photograph of the employee to safeguard the welfare of service users. The manager stated staff have induction and foundation training and a review of records confirmed the home had an induction checklist which covered the aims of the home, policies and procedures, and documents and recording. Further evidence indicated staff have appraisals and training is linked to the needs of service users including advanced autism, challenging behaviour, restraint and other appropriate and relevant training. Following discussions with the manager a requirement has been made for induction records to be dated and signed by the employee and named supervisor. The manager confirmed the company will be introducing a new induction programme based on Skills for Care common induction standards to ensure service users joint needs are met by appropriately trained staff. Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39&42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the day to day management of the home are good ensuring service users benefit from a well run home. Quality assurance at the home is good reflecting the views of service users, relatives and stakeholders. The systems for health and safety are good safeguarding the welfare of staff and service users. EVIDENCE: The home has a manager who has submitted an application for registration with the CSCI. The manager is currently doing the RMA (Registered Manager Award) qualification and is due to complete the programme in January 2007. Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 23 The inspector noted the manager was aware of her role and responsibilities with clear lines of communication and accountability in the home. During discussions a member of staff stated ‘‘management is very nice, co-operative and very solid’’. The home has a policy on quality assurance and used questionnaires to obtain feedback about the home. Further evidence confirmed a survey of relatives, service users and other agencies undertaken in March 2006 with a report available for information in the home. A review of records confirmed the home had regular Regulation 26 (monitoring visits) with appropriate management action taken and observations confirmed the home had met the requirements made by the CSCI to improve practice at the home. It is recorded by a relative in a comment card ‘‘there is a great deal of communication between myself and the staff at Briar House’’. The home had a policy on health and safety and staff have training in health and safety, food hygiene, fire safety with two appointed first aiders in the home. Further evidence confirmed the home had a current gas safety certificate, service inspection report on fire equipment, emergency lighting and a certificate to confirm a legionella bacteria test had been completed with no recommendations made. The kitchen appeared clean and hygienic and fridge and freezer temperatures were within normal limits to promote food safety. The home had a policy on COSHH (Control of Substances Hazardous to Health) with products appropriately stored to promote health and safety. Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 x 29 x 30 2 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 2 3 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 3 x 3 x 3 x x 3 x Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 25 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(2)(b) Requirement Timescale for action 19/01/07 2 YA30 3 YA32 4 YA35 The registered person must arrange a care plan review for a service user involved in an investigation under safeguarding adult procedures to promote personal safety. 13(3) The registered person must 10/02/07 ensure staff have training in infection control to safeguard the welfare of staff and service users and promote health. 18(1)(a) The registered person must do 01/02/07 an action plan with timescales outlining how the home will meet NVQ training targets to ensure service users are supported by competent and qualified staff at all times. 18(1)(c)(i) The registered person must 01/02/07 ensure the homes induction records are dated and signed by the employee and named supervisor to ensure the joint needs of service users are met by appropriately trained staff at all times. Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA7 Good Practice Recommendations The registered person shall consider ensuring information about service users’ meetings is in a format which is understandable by service users to promote communication and decision making in the home. The registered person shall consider ensuring handwritten prescriptions on medication record sheets are dated and signed and witnessed by a second member of staff to promote good practice. The registered person shall consider ensuring a recent photograph of service users is in the medication folder for information. 2 YA20 3 YA20 Briar House DS0000062117.V320260.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Briar House DS0000062117.V320260.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. 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