Inspection on 25/04/05 for Brook Lodge

This inspection was carried out on 25th April 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brook Lodge 23/04/08

Brook Lodge 27/06/07

Brook Lodge 09/10/06

Brook Lodge 02/11/05

Brook Lodge 17/12/04

Brook Lodge 28/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Windfall House Latchen Longhope Glos GL17 0QA Lead Inspector Lynne Bennett Unannounced Monday 25 April 2005 11:00 th 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 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 Stationary 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. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Windfall House Address Latchen Longhope Glos GL17 0QA 01452 830072 01452 830072 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Voyage Limited Mrs Jeanie Elizabeth Sherwood Care Home - Personal Care 10 Category(ies) of Learning Disability (10) registration, with number of places Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/12/04 Brief Description of the Service: Windfall House consists of two semi-detached cottages, one known as Windfall House and the other as Brook House. Both have independent front doors and are connected by an internal door at the rear of the property. The homes are registered with the Commission for Social Care Inspection as Windfall House. Windfall House is one of several residential homes in the area managed by Voyage Homes. Service users living at the home have an identified learning disability and may present challenges to the service. Brook House has a lounge, kitchen/diner, two ground floor bedrooms and a further three on the first floor. There are bathrooms on both the ground floor and first floor and both have a bath, separate shower and toilet. Windfall House has a lounge, large dining room, kitchen, one ground floor bedroom, and a further four bedrooms on the first floor. There is a ground floor toilet and on the first floor there is a bathroom with bath, separate shower and toilet. There is also an additional toilet on the first floor and an office/store room. On the ground floor there is a staff sleep-in room. A separate office is situated in the garden, close to house. There are gardens to the front and rear of the property amounting to 0.25 acres. The service users have allotments next to the home where they can grow vegetables. An additional self contained flat has been added to the property. Major refurbishments of the home are planned for June 2005 when people living there will move to alternative accomodation until completion in September 2005. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours on a day in April 2005. Time was spent with the people living at Windfall; verbal feedback was received from five people. The registered manager and people living at the home showed the inspector round the premises. The care for two people was looked into in some depth and the care of others discussed with staff and management. Care plans, medication and financial records were looked at in some depth. Also examined were staff files for three members of staff, who were spoken to in addition to other staff on duty. Health and safety records were also examined. Comment cards were sent to other professionals involved in the care of people living in the home. Subsequent to the inspection a meeting was held to discuss whether the person wishing to remain at Windfall during the alterations could remain at the home safely and with the appropriate support. It was decided that in the best interests of the person they would be informed that this would not be possible. Requirements in this report remain and must be complied with should the person remain at Windfall when other people move to Herefordshire. What the service does well: What has improved since the last inspection? The quality of care plans and risk assessments has improved. There is regular monitoring and review of these records. All people living at the home have had an annual review with representatives from their placing authority and family or have reviews scheduled. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 6 A system to monitor the quality of care being provided at the home has been introduced. People living at the home have been involved in this process. 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. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 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 standard(s) 1 and 5. The home has produced a Statement of Purpose and Service User Guide that provide prospective service users with information about the home enabling them to make a decision about whether the home meets their needs. EVIDENCE: The home is presently due to be completely refurbished. People living there will be moved temporarily to accommodation in Herefordshire. A major variation has been submitted to the Commission. Windfall House has two vacancies at present. Applications from prospective service users will be considered to move into the home once the refurbishment is completed. The Statement of Purpose and Service User Guide were reviewed in line with requirements of the last inspection. The registered manager confirmed that people living at the home do not make a contribution towards the cost of transport. These documents will need to be reviewed after the refurbishment of the home to indicate the environmental improvements and the change of name to Brook House. The home will also be providing care to 11 persons with a learning disability. People living at the home have a statement of terms and conditions in place that requires amending to reflect that the agreement is with Voyage and not Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 9 Headwind, the former providers. This is an outstanding requirement from the last two inspections. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 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 standard(s) 6,7 and 9. People living at the home are involved in care planning and annual reviews providing consultation about their lifestyles and choices. Risk assessments support people at the home to challenge and deal with problem areas in their lives enabling them to take risks as safely as possible. EVIDENCE: Two people living at the home were case tracked. This involved examining their files, care plans, risk assessments and medication records. They were spoken to as well as their key workers. There has been an improvement in the systems in place for monitoring and reviewing of care plans and risk assessments. Staff confirmed that annual reviews including representation from the placing authority and families are taking place. This meets with requirements issued at the last inspection. It was evident that care plans and risk assessments are being amended to reflect these reviews and also changes to identified need on a more regular basis. People living at the home said that they have good relationships with their key workers and are supported to make choices about their daily lifestyles. Some people are signing records in their files. Records confirming any restrictions to choices or freedoms are signed and dated. These should be reviewed. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 11 Records are kept recording any incidents or accidents. CALM records and ABC charts supplement these. There was some inconsistency when crossreferencing these records. Staff should ensure that these records are completed There was evidence that risk assessments are being reviewed and amended as a result of incidents. Staff spoken to have a sound awareness of the risks involved supporting people in the community. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 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 standard(s) 12,13,14,16 and 17. Educational, social and recreational activities are being scheduled although staff availability is occasionally insufficient to meet the needs of the people living in the home. A variety of freshly prepared meals are provided offering choice and catering for special dietary needs. EVIDENCE: People living at the home are offered a range of activities including attending day centres, colleges, work placements and leisure centres. One person spoken to enjoys ten-pin bowling and others said they like going to the local shop and shopping in Gloucester. Several said that they like to go for drives into the Forest and one said that he likes going for walks. The pub and cinema also appear to be very popular. There are times when some people living at the home choose not to take part in organised activities. Staff keep a record of activities that have been refused. Staff indicated that at times due to levels of staffing and the needs of some people living there, these activities may not be able to go ahead. The registered person must ensure that staffing levels are sufficient to meet the needs of people living at the home. (See Standard 33) Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 13 Staff are making preparations for the temporary move to Herefordshire and are exploring leisure and recreation activities that may be accessed as well as ensuring continuity with activities and commitments already established from Windfall. People living at the home are encouraged to help with activities of daily living. One person living at the home takes responsibility for meeting and greeting guests, ensuring they sign the visitors’ book. Others help with the weekly grocery shopping. A cook is employed by Voyage who prepares a hot meal for either lunchtime or the evening meal depending on the activities of the people in the home. On the day of the inspection people enjoyed a pasta bake. A full record of meals is not presently being kept – these were previously recorded on daily notes. Meal records must be maintained. The cultural needs of one person living at the home are reflected in the provision of meals. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 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 standard(s) 18,19 and 20 People living at the home have access to a range of healthcare professionals ensuring their healthcare needs are met. Medication systems need to be improved to minimise potential risks to people at the home. EVIDENCE: The ways in which people living at the home prefer to be supported with their personal and healthcare needs are clearly recorded in their files and care plans. Staff spoken with had a clear understanding of their needs and preferences. People living at the home are registered with a Doctor and Dentist, receive regular chiropody and attend Optician appointments as necessary. Thorough notes are kept for appointments with Doctors and outpatient appointments. They are not being kept for other appointments. These are recorded in the diary. Evidence should be provided on their files of healthcare appointments. The Community Learning Disabilities Team provides support for several people living at the home. There was also evidence of referral for incontinence advice. A person has recently received medical treatment and there was evidence of ongoing consultation and discussion about future treatment and care. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 15 Whilst people are living in Herefordshire they will receive continuity of care from healthcare professionals they would normally access whilst residing at Windfall. Staff are responsible for administration and control of medication. They attend training in the safe handling of medication. Most of the medication is supplied in a monitored dosage system. Pro Re Nata medication is supplied separately. There appeared to be no stock records in place for this medication. Two tablets (identified as Diazepam) were in an unmarked container in the cupboard. These must be disposed of and staff given guidance of what to do should Pro Re Nata medication be refused. The home’s medication policy and procedure should be reviewed in line with the current PCT guidelines. Consent forms must be in place for the administration of medication by staff for people living in the home. Liquids and creams in use had not been labelled with the date of opening. Handwritten entries on the administration record must be signed and countersigned by two members of staff. There were several homely remedies in the cupboard. A record of homely remedies used by the home must be authorised by a pharmacist. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 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 standard(s) 23 The financial management of personal finances is not satisfactory preventing people living in the home from having control over their personal monies. EVIDENCE: Staff receive training in Crisis and Aggression Limitation Management (CALM) and escape techniques. Refresher training is provided on an annual basis and Voyage monitor the use of physical intervention. There appears to have been an increase in the use of physical intervention since the last inspection. The Commission has received notification of some of the incidents. Where two members of staff are involved in a physical intervention with a person living at the home, the Commission must be informed. Staff spoken with confirmed their understanding of the needs of people living in the home and the importance of the use of verbal de-escalation and diffusion. There was evidence that staff monitor situations likely to put people living in the home at risk of possible abuse. Other professionals are involved where appropriate. One of the people living at the home has chosen to stay at Windfall during the relocation to Herefordshire. Voyage have respected this wish and built a self contained flat. Staff will support the person. The registered person must ensure that risk assessments and guidelines are in place for staff who will be lone-working during this period. (See also Standard 33) Bank accounts have been opened for all people living at the home. There has been an additional delay caused by the signatories for these accounts who are not accessible to the service on a day-to-day basis. People living at the home have been using the petty cash system for personal expenditure. They must Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 17 have access to their bank accounts and be supplied with information about their current balances. They must also be supplied with information about transactions that have taken place between themselves and Voyage. An immediate requirement was issued. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 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 standard(s) 24 The standard of the environment within this home is poor. Plans to completely refurbish the property will significantly improve the environment and décor providing better facilities for the people living there. EVIDENCE: Plans have been submitted to the Commission for the complete refurbishment of the home. There will be ten single rooms with en suite facilities. Communal spaces will be sufficient to meet their needs. The kitchen will have new fixtures and fittings and there will be a new laundry. In addition there is a self-contained flat that has already been built and furnished. This accommodation must have the necessary fire equipment installed such as a fire blanket/fire extinguisher. Provision must also be made for the secure storage of medication and money. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35 and 36. Fluctuating staff levels may on occasions impact on the standard and consistency of care being provided. Robust systems are in place to monitor the training needs of staff ensuring a competent and qualified staff team. EVIDENCE: At the last two inspections it was identified that staffing levels are on occasions falling below the agreed minimum of five staff per shift. It was hoped that vacancies would be filled by early 2005 but this has still not been achieved. Two new staff are due to start work but the home still has staffing shortfalls. The pressure on the staff team is likely to increase with the planned relocation to Herefordshire. Voyage must ensure that there are sufficient staff employed to cover both the self-contained flat and the temporary residence. This must also take into account contingencies for any changes of need for the person living in the flat such as an increase in staffing. The registered person must notify the Commission when staff levels fall below the agreed quota. Voyage has been requested to supply information for consideration by the Commission about the staffing levels they consider appropriate during the relocation to temporary premises. Staff spoke positively about changes to the structure of the rota. They are now working in one of three teams with a team leader. They felt that this was Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 20 providing continuity of care and consistency in approach. The registered manager was hopeful that the teams would be increased to five full-time members of staff supplemented by part-time staff. The organisation’s Human Resources department manages recruitment and selection of staff. Files for the two new members of staff were still at Head Office. One member of staff started working at the home in December 2004. These records must be kept at the home. Other files examined contained evidence of two references, a Criminal Records Bureau check and a PoVA first check, evidence of identity and a photograph. Criminal Records Bureau checks for other staff were sampled. The organisation can now dispose of these. Voyage provides a comprehensive training programme from induction including CALM training and core training to a NVQ Programme. Eight staff have a NVQ and four are working towards an award. A training matrix indicates when refresher training is due. Staff acknowledged that they have access to regular training and support from the management team to achieve NVQ Awards. The senior staff team have received training in supervision skills and a schedule of supervisions is being established. People living at the home spoke positively about the staff team and the support they receive. Staff were observed treating them with dignity and respect. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,41 and 42. The manager is supported well by her senior staff team in providing clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities. Systems monitoring the health and safety of the home must be improved to ensure the provision of a safe environment. EVIDENCE: The registered manager has substantial experience supporting adults with a learning disability. She has the Registered Managers Award at Level 4. Staff spoke highly of the manager and the management team saying that they have worked hard to improve the quality of care and the standards within the home. Staff said that the manager is open and approachable and they felt she would challenge poor practice. People living at the home appeared to have a positive relationship with the manager, seeking her advice or help during the inspection. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 22 Voyage completes monthly-unannounced visits to the home and sends a copy of these reports to the Commission. A survey was conducted with people living at the home focussing on activities, living at the home and meals. A survey has also been sent to relatives requesting their views. Accident and injury records must be kept securely. Other records are kept in lockable facilities, although the cupboard in the dining room where personal records are kept was unlocked at the time of the inspection. Staff complete training in first aid, fire, moving and handling, infection control and basic food hygiene. Night staff must receive training every three months. Fire records have been maintained until recently. The registered manager must ensure that in the absence of key personnel delegated tasks such as testing fire equipment and holding drills are completed and recorded. Portable appliance testing is also overdue. Records are being maintained for the temperatures of fridges and freezers as well as food temperatures. Additional environmental and fire risk assessments have been put in place whilst there is building work in progress at the home. Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 2 Standard No 22 23 ENVIRONMENT Score x 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 2 x 3 2 Standard No 31 32 33 34 35 36 Score x x 1 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Windfall House Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 2 2 x D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 24 YES 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 1 Regulation 6 Requirement The Statement of Purpose and Service User Guide must be reveiwed in light of the environmental changes and change of name The statement of terms and conditions for each service user must be reviewed to reflect current fees and costs of extras. The name of the Commission must be changed. (Previous timescales of 30/9/04 and 31/3/05 not met) The registered person must ensure that there are sufficient numbers of suitably qualified staff working at the home to ensure the health and welfare of service users. (Previous timescales of 31/7/04 and 31/3/05 not met) Full records of meals provided must be kept. The home must ensure the safe administration and control of medication as indicated in the text. The Commission for Social Care Inspection must be informed of instances affecting the well being of service users - such as Timescale for action 30 Sept 2005 2. 5 17(2)Sch. 48 5(1)(b) 30 May 2005 3. 14 12(1) 18(1)(a) 30 May 2005 4. 5. 17 20 17(2) Sch 4.13 13(2) 25 April 2005 25 May 2005 25 April 2005 6. 23 37 Windfall House D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 25 physical intervention. 7. 23 12(5) 13(4)(c) Risks to the service user remaining at Windfall must be minimised and potential risks to staff must be identified and contingency plans put in place. Service users must have access to their bank accounts and be supplied with records of current balances and transactions with Voyage. The necessary fire equipment must be provided in the self contained flat. Secure storage must be provided for medication and money in the self contained flat. The regsitered person must ensure that there are sufficient staff employed to meet the needs of the person living in the flat and people living in the temporary residence. The Commission must be informed when staff levels fall below the agreed levels. Staff files must be kept at the home and include all information as listed in the Schedule. Accident and injury records must be stored securely. Regular fire drills and testing of equipment must be put in place. Night staff must receive training every three months. Portable appliance testing must be completed. 31 May 2005 8. 23 17(2) Sch 4.9 25 May 2005 9. 10. 11. 24 24 33 24(4)(a) 13(2) 16(2)(l) 18(1)(a) 31 May 2005 31 May 2005 31 May 2005 12. 13. 14. 15. 33 34 41 42 37 19(1)(b) Sch 2 1-7 17(2) Sch 4.12(a) 23(4)(c) (d) 23(2)(c) 25 May 2005 25 May 2005 25 May 2005 25 May 2005 25 May 2005 16. 42 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations D51_D03_S44223_WindfallHouse_V223713_250405_Stage4.doc Version 1.30 Page 26 Windfall House 1. 2. 3. Standard 6 7 19 ABC and CALM records should be completed for all incidents. Records of any restrictions in place should be reviewed. Records of appointments with all healthcare professionals should be kept. 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