Inspection on 22/08/06 for Bridgewood Mews

This inspection was carried out on 22nd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bridgewood Mews 14/05/07

Bridgewood Mews 12/12/05

Bridgewood Mews 15/06/05

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOME ADULTS 18-65 Bridgewood Mews 38 Bridge Road Tipton West Midlands DY4 0JW Lead Inspector Mrs Amanda Hennessy Key Unannounced Inspection 22nd August 2006 10:00 Bridgewood Mews DS0000062330.V308208.R02.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 Bridgewood Mews DS0000062330.V308208.R02.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. Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bridgewood Mews Address 38 Bridge Road Tipton West Midlands DY4 0JW 0121 522 5780 0121 522 5781 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) Exemplar Homes Ltd Kathleen Felton Care Home 20 Category(ies) of Physical disability (20) registration, with number of places Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2005 Brief Description of the Service: Bridgewood Mews is a purpose built home and can accommodate up to 20 younger adults who are physically disabled and may require nursing care. Accommodation is on two floors, each floor having a lounge, dining room and a further quiet lounge. Resident’s bedrooms are on both floors. There is access to the first floor by a passenger shaft lift. All bedrooms are single occupancy each with en-suite facilities consisting of toilet, hand basin and shower. The main kitchen is on the ground floor with the laundry on the first floor. The home is privately owned by Bridgewood Mews Healthcare. The home is situated a mile from Great Bridge and is easily accessible via public transport route to local areas, Dudley and West Bromwich. The home has an experienced Manager. There is a registered nurse on duty on each floor twenty-four hours a day assisted by a team of care staff. Fees vary between £548 and £1575 and are dependant on the needs of the service user and the type of room that will be occupied. Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by one inspector. The inspection was carried out between 10.00 and 19.30. The inspection included a tour of the home, talking to service users and staff and a review of service users questionnaires which had been returned to the Commission for Social care and Inspection prior to the inspection. A review of information supplied by the Manager (pre inspection questionnaire) was also undertaken and expanded upon during the visit. Care records were reviewed as part of the “case tracking” of six service users. The home has been open since January 2005 and is now almost fully occupied with service users now accommodated on both floors. Both requirements of the previous inspection have been met. Nine requirements were made as a result of this inspection. The Inspector would like to thank the Home Manager, Area Manager, staff and service users for their assistance and hospitality during the inspection. What the service does well: The home is clean, welcoming and homely and meets its service users needs. Comments from service users were positive and included: “it’s the best home in Birmingham” and “ It’s a very good home, although I would still like to go home”. All service users have a comprehensive assessment of their health needs prior to their admission to the home. They receive sensitive care with staff exploring their preferred likes and dislikes such as preferred gender of staff, time getting up and going to bed, type of bed, bed linen, food preferences and whether they prefer a bath or shower and how frequently. Service users are enabled to access the local community and are able to maintain and develop relationships both with their families and friends. Service users say that the food is good they always have a choice. Menus show that meals are balanced, nutritious and varied to suit the needs of service users. The home has robust recruitment and selection policies and procedures that safe- guard its service users. Bridgewood Mews DS0000062330.V308208.R02.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. Bridgewood Mews DS0000062330.V308208.R02.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 Bridgewood Mews DS0000062330.V308208.R02.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): 1,2,4 The overall outcome for this group of standards is judged to be good. Service users can be assured that their health needs will be assessed prior to their admission to the home, required information about the home is available and staff have the necessary skills to meet their needs. EVIDENCE: The Statement of Purpose and service users guide are reviewed and kept updated providing current and prospective service users with a good source of information about the suitability of the home and the services they offer. Service users are admitted following a comprehensive assessment of their needs undertaken by a senior member of staff. It is not always evident that staff are aware of service users aspirations prior to their admission (such as “ I would like to go to college”) and whether they can be met, with assessments generally focusing on their health needs. Service users or their representative are involved in the assessment of their needs. A letter is given prior to admission confirming that assessed needs can be met by the home. Service users and their families are encouraged to visit the home before making the decision to come and stay with some service users coming to stay for a meal or over night, sadly other service users due to their health are unable to visit. Bridgewood Mews DS0000062330.V308208.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 The overall outcome for this group of standards is judged to be adequate. Care planning does not always represent all areas of the service users life. There is a need for staff to ensure that service users are enabled to make decisions about their lives and are supported to do so. EVIDENCE: All service users have a plan of care which identifies how service users health care needs will be met. Care plans do not always clearly identify service users goals and aspirations and need further development in relation to social support and rehabilitation. Service users consistently stated that they were able to go out with staff but this was dependent on staffing levels. Service users do out most days in the homes mini bus but this needs to be more structured, planned and based on service users individual need rather than every one going to the local supermarket or park. Staff do generally support service users choices and decision making but this is not always consistent they need to be ensure that they recognise that service users have a right to make decisions which is facilitated unless a restriction in choice or personal freedom is identified by a risk assessment. Concerns were Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 10 raised when a service user wanted their door locking but staff were uncomfortable with this. Service users have also previously identified restrictions in freedom such as not being able to store their own alcohol and being unable to give their own medication, this may be entirely appropriate but must be clearly identified within a risk assessment and which is then discussed and explained to the service user. Information on advocacy services is available and is prominently displayed on the main notice board should service users wish to contact advocacy services independently. It was pleasing to hear that the home has several service users who manage their own money with other service users supported by staff and their families to manage their own finances. The home has some service users who have challenging behaviour although risk assessments and care plans do not always adequately describe how this behaviour will be managed. The home needs to develop their risk assessments to ensure that service users and their carers understand why risks or when appropriate restrictions or limitations within the home. Bridgewood Mews DS0000062330.V308208.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 and 17 The overall outcome for this group of standards is judged to be adequate. Service users are able to access the local community and are able to maintain and develop relationships both with their families and friends. Service users are encouraged to exercise choice and control over their lives although this needs further development. Food is nutritious and varied and is suitable for the service users and their special dietary needs. EVIDENCE: Staff try to ensure that service users are able to take part in age, peer and culturally appropriate activities. One service user has expressed a wish to attend college and staff are currently exploring this possibility. Service users said that they regularly go out and have recently been to the cinema, pubs, shopping centres, church, visits to family members homes as well for walks to the local park. Service users said : “ visits outside the home can sometimes this can be limited due to staffing levels.” Service users benefit form the home having its own mini bus, which was in use Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 12 during the inspection taking service users to the local supermarket. One of the lounges has been developed into a sensory room for those service users who are unable to or do not wish to go out of the home. Family and friends are welcomed to the home and are encouraged to continue to be involved with their loved ones. Staff and service users spoken to confirmed that service users regularly visit their families and are able to choose who they see. One service stated that messages from her family were not always passed on to her. A quiet room is available should they wish to see their visitors in private. Service users confirmed that they have a good relationship with the staff with staff treating them with respect. The following comment was typical of comments received about staff: “ carers are very good and also the nursing staff” It was evident that staff do not enter bedrooms without the service users consent. Bedroom door keys are available but records seen identify that staff are uncomfortable with service users locking their bedroom door at night as identified earlier in this report. It is recommended that the type of door lock is reviewed so that service users can get out of their room without the use of a key, whilst it is locked from outside. The home has a three week menu which the cook has developed to meet service users likes and dislikes. The care staff and cook liaise closely to ensure that service users likes and dislikes are catered for with a list of food preferences completed by the service user or their family at the time of their admission, an effective communication book and also by the cook serving out meals. The home provides special diets such as diabetic and soft . The cook ensures that the special diets both safeguard service users from the risk of choking and are also being tasty and nutritious. Mealtimes are flexible and unrushed, with service users able to choose when and where they eat. The cook maintains appropriate records for the safe keeping of food. Bridgewood Mews DS0000062330.V308208.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 The overall outcome for this group of standards is judged to be good. Service users receive sensitive care that meets their needs. There are appropriate policies and procedures for the safe keeping and administration of medication but staff do not always apply the policies consistently. EVIDENCE: Care records comprehensively identify service users preferences such as preferred gender of care staff, preferred style of clothing and preferred colours of clothing such as “likes casual clothing”, use of toiletries, preference of and frequency of a bath or shower, preferred time of going to bed and getting- this varied greatly between all the service users accommodated from 9.00 to one resident who liked to get up at twelve. Staff spoken to were able to identify residents individual needs and ensure that they are met. Staff ensure that there is consistency of care with the use of key workers who work closely in partnership with the resident and their family. The home has good links with other Health professionals and specialist organisations such as the Huntingtons Society, Tissue Viability Nurse Specialist, Speech Therapists, Physiotherapists and GPs. Staff also ensure that Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 14 service users have required specialist equipment that both supports their independence whilst also protecting their health. The home have appropriate medicine policies and procedures. Slight omissions and inconsistencies in practice were seen with staff not always signing to confirm that all medicines had been given or the reason why it had not been given. Staff do not routinely sign to confirm the receipt of medicines in to the home as required. One service user was found to have a duplicate treatment sheet which may give the potential for a drug error. Staff do record the drugs fridge temperature every day but also need to record the treatment room temperature where medicines are stored particularly as the treatment room was found to be uncomfortably hot on the day of the visit. Staff generally record the opening date of short life medicines but need to ensure that they also do this when they open bottles of calogen which they are not currently doing. The home safely stores and administers controlled drugs. Records demonstrated that staff monitor residents condition and refer them to their GP when appropriate. Bridgewood Mews DS0000062330.V308208.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The overall outcome for this group of standards is judged to be poor. Service users are listened to but staff do not always undertake required and informed actions to protect them from abuse, neglect or self harm. EVIDENCE: The home has a detailed complaints procedure which is displayed in the main reception area of the home and is also in the service user guide. Service users said that they were confident about who to raise there concerns to. The Commission for Social Care Inspection has received two complaints about the home since the previous inspection both complaints were partially upheld and related to staffing levels and restrictions in freedom. The home has received a further three complaints which were made directly to the home. Service users recorded identified individual concerns had not been recorded formally and there was no record of any investigation or outcome of the complaints. One service user had made a complaint that should have resulted in an Adult Protection referral but this had not been undertaken. CSCI should also have been notified of these incidents, which was not the case. The home has appropriate policies to safe guard residents from harm and potential abuse and also for staff to highlight concerns whilst feeling safe to do so. However the Manager did not undertake required actions following allegations of abuse. The home has service users who display challenging and frequently aggressive behaviour but have failed to notify CSCI of incidents that have adversely affected service users. One service user had asked for their bedroom door to be locked at night due to fear of this service user. Staff have all received recent training in the identification, awareness and action to be taken if abuse is alleged. Bridgewood Mews DS0000062330.V308208.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 The outcome indicator for this group of standards is judged to be excellent. Service users live in a clean, homely and safe environment that meets service users needs. EVIDENCE: The home is decorated and furnishings to a high standard. The home has bedrooms, lounge, dining room and a quiet lounge on each floor. All bedrooms are single and ensuite. Service users may choose either a double or single bedroom and are encouraged to bring in treasured items from home. All areas of the home seen were clean, welcoming and free from any offensive odour with the Housekeeper taking particular pride in the home. The home has a wide variety of specialist equipment to care for dependent people whilst also maximising their independence. Staff undertake a comprehensive assessment of service users which includes an assessment of equipment required, to ensure that ensure all required equipment is made available to them. A passenger shaft lift enables service users access to both floors. There are appropriate infection control systems in place. The laundry and laundry systems meet infection control guidance. Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. The outcome indicator for these groups of standards is judged to be adequate. The home has recruitment and selection policies and procedures that safeguard its service users. Training opportunities are generally good but training must highlight more effectively the needs of younger adults and new staff do not complete required induction training within required timescales. EVIDENCE: A registered nurse on duty twenty-four hours a day on each floor supported by a team of care staff. The skill mix of the staff on duty generally meets service users needs however records identify that staff may not always recognise the needs which revolve around choice for younger adults. Care staff are supported by two full time “Life skills coaches” whose role is predominantly centred around ensuring that service users social needs are met. Staff receive regular training to ensure that they are aware of features of the service users illness, understand their challenging needs and ensure that care is given on a “person centred” basis. Further training to reinforce care of younger adults is required. It is pleasing to see that consistently staff consult with other specialists to ensure that specialist areas of service users care and needs are addressed. The home has recruitment and selection procedures that are robust and protect vulnerable people. Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 18 The home has 8 of its 23 (35 ) care staff with a minimum of National Vocational Qualification (NVQ) level two or above. Further staff have enrolled to undertake their NVQ 2, enabling the home to work towards the requirement of a minimum of 50 of care staff with NVQ or above. Staff receive do receive induction and foundation training, but there was no evidence that recently appointed staff have received any induction despite them being in post for moiré than six weeks. Staff have at least five training days each year with a training and development plan which links to the homes aims and service users needs. Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The outcome indicator for these groups of standards is judged to be adequate. Appropriate actions are not always undertaken when service users raise concerns. Service users must be listened to which would give assurance that the health, safety and welfare of service users are fully promoted and protected. EVIDENCE: The home has an experienced Manager who is also a registered nurse. Mrs Felton has been Home Manager since the home manager opened, and was previously a home manager at another home for several years. The Manager is well respected by staff who feel that she is approachable. The manager conducts monthly audits of accidents, complaints and pressure sores. A service user survey has been undertaken with a report available of its findings, which is available for all interested parties including the Commission for Social Care Inspection. Staff must ensure that service users concerns are brought to the attention of the Home Manager to ensure they are fully Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 20 investigated to fully meet this standard. The home and its staff act on advice given by the Commission for Social Care Inspection and consequently has addressed all previous requirements. Procedures to protect service users include regular and required checks on the fire alarm, emergency lighting, fire extinguishers, nurse call points and hot water. Records identify that staff regularly attend mandatory training in fire safety, moving and handling, food hygiene, first aid, health and safety, infection control and protection of vulnerable adults. Maintenance records and contracts were reviewed and were found to be up to date. The Manager must ensure that all staff receive induction training that includes safe working practices and that all incidents that affect service users well being are reported to the Commission for Social Care Inspection to fully meet this standard. Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 1 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 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 x x 2 x Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 Requirement Service users goals and aspirations must be identified prior to the service users admission to enable staff to assess whether these aspirations may be met and this must be communicated to the service user. When service users have restrictions in their freedom identified this must be clearly identified within a risk assessment which is then discussed and explained to the service user. The registered person must ensure: There are no gaps on the medicine record. Staff sign to confirm the receipt of all medicines in to the home. Staff act appropriately to protect service users from potential drug errors. Timescale for action 30/09/06 2 YA7 12(2) 30/09/06 3 YA20 13(2) 20/09/06 Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 23 The treatment room temperature is recorded daily. The treatment room temperatures are below 25°c. All short life medicines have a date of opening recorded. The registered provider must ensure that there is a record of all complaints made within the complaint log that is made available for inspection by CSCI. The registered provider must ensure that adult protection procedures are met. The registered provider must ensure that The Commission for Social Care Inspection is informed of all incidents that affect service users health, safety and well being. The home must have 50 of its care staff with NVQ level 2. Staff must receive training/ supervision that highlights the needs of younger adults. New appointed staff must receive induction training within 6 weeks of their commencement of employment. 4 YA22 22 20/09/06 5 6 YA23 YA23 13(6) 37 20/09/06 20/09/06 7 8 9 YA32 YA32 YA35 18 18 18 31/03/07 31/12/06 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA16 Good Practice Recommendations It is recommended that the type of door lock is reviewed so that service users can get out of their room without the use of a key, whilst it is locked from outside. Bridgewood Mews DS0000062330.V308208.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Bridgewood Mews DS0000062330.V308208.R02.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. 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