Inspection on 26/06/07 for Charles Court

This inspection was carried out on 26th June 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Charles Court 14/03/06

Charles Court 15/11/05

Charles Court 14/02/05

Charles Court 15/09/04

Charles Court 09/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Charles Court Northfields Strensall York YO32 5XP Lead Inspector Gill Sample Unannounced Inspection 26th June 2007 10:10 Charles Court DS0000015792.V335856.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 Charles Court DS0000015792.V335856.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. Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charles Court Address Northfields Strensall York YO32 5XP 01904 491589 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) Joseph Rowntree Housing Trust Anthony Egan Care Home 15 Category(ies) of Learning disability (15), Learning disability over registration, with number 65 years of age (3) of places Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of service users over the age of 65 should not exceed 3 at any one time. The category LD (E) is only for use by current service users who have reached 65 and above whose needs can still be met by the home. Date of last inspection Brief Description of the Service: Charles Court is a purpose built single storey care home jointly managed by the Joseph Rowntree Housing Trust and the York Mencap Hostels Association, which provides long-term residential care for fifteen people with learning disabilities three of whom may be over 65. The home also provides short term respite care using one bedroom. The home is situated in the large village of Strensall, five miles north of York, and is within easy walking distance of a range of facilities, which include shops, pubs and community centres. A regular bus service operates between the village and York city centre. The standard fees charged by the home range from £332.83 to £819.58 per week. Toiletries, taxi fares, hairdressing and activities outside of the home are not included in the fees. This information was provided by the registered manager on 8th March 2007. Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: ● ● ● ● ● ● Reviewing information which has been received about the home since the last inspection Information provided by the manager on a pre-inspection questionnaire Comment cards returned from people living at the home using a link resident to distribute and collect these comment cards. Written surveys from relatives, carers and advocates of residents Written surveys from health professionals involved with the service A visit to the home on 26th June 2007 The visit to the home lasted six and a half hours. The inspector spoke to people who live at the home, the registered manager Anthony Egan and care staff on duty. Records relating to people living there, staff and the management activities of the home were inspected. Care practices and routines of the home were seen. This helped the inspector to gain an insight into what life is like at Charles Court for the people who live there. The registered manager Mr. Egan assisted the inspector and he was given verbal feedback at the end of the inspection. There are good outcomes for people who live at Charles Court. However, the future of the service is currently under review and the process will take several months before any outcome is known. In the process of this inspection, people who live at Charles Court and their relatives said they were anxious and worried about this. It will be necessary for the organisation to keep all parties informed of the progress of the review so that any issues can be raised and people’s anxiety levels managed. What the service does well: The service is able to care for people with a range of needs, and provide care on an individual basis. There were examples of good practice seen and staff related well to people with warmth and sensitivity. People are well supported to make their own decisions and follow their own lifestyle, and live as independently as they wish. “I can do what I want” “treats my (relative) with respect, provides a safe and stimulating environment in which to live.” People who live at Charles Court and their relatives praised the carers “The staff are caring and do a good job”. About the food one said “nice choice, it’s brilliant”. Charles Court DS0000015792.V335856.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. The summary of this inspection report can be made available in other formats on request. Charles Court DS0000015792.V335856.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 Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. People know what to expect from the service before they move in and can be confident that their needs will be met. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Records of two people living at the home were seen. One of these people had been recently admitted to Charles Court. Records showed that in depth information has been gathered about the person prior to them coming into the home which reflected both the needs and wishes of the individual such as developing skills and continuing interests. Information about the home is available to prospective residents and their families so that they can make an informed choice about coming to live there. Information sent prior to the inspection showed that advocacy services had been used and are available to help people make decisions of this nature. License agreements explain to the people who live in the home, how much they have to pay and the terms and conditions of living in the home. The home has one place to offer a respite care service which provides an opportunity for people to experience the service before deciding to move into the home. Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use the service experience good quality outcomes in this area. People are supported and encouraged to make their own decisions about how they live their lives. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Written care plans were in place for people who live at the home. Care plans seen detailed the care needed based on individual aims and objectives. Mr. Egan said that he had developed the care planning system based on providing care to address individual identified needs. Formal reviews of care with the purchasing authority were on file. Reviews made of care had been noted by dating each objective. Advice was given so that it would be possible to follow any changes more clearly. Care plans seen were not signed by those receiving care so it was not possible to say that the plans had been drawn up with the involvement or agreement of individuals. Risks associated with the personal needs of people, the provision of care or activities had been recognised and recorded, and detailed how risks were to be minimised. Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 10 The home operates a key worker system where a member of staff takes specific responsibility to make sure that people have everything they need and can be supported in making choices. Written information from people living at the home said that they were involved in making decisions in the home. Staff were seen supporting people to make choices at the visit. People said they had been given information about the future of the home at a recent residents’ meeting. People have the opportunity to influence the service and make suggestions about how the home is run. People were seen making their own hot drinks and said they were involved in preparing food “we help making sandwiches”. Regular residents’ meetings are held and notes reflected the issues which people had raised. Advocacy services independent of the service are available to assist people make important decisions about their lives. Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use the service experience good quality outcomes in this area. People are supported to live meaningful lives and have good access to a wide range of both social and therapeutic activities. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People are involved in outside activities providing them with leisure and social opportunities and personal development, such as college. Two people said they were looking forward to spending time with relatives, going for the weekend or on holiday with their families. People’s bedrooms reflected their interests and hobbies and people had their own television and music systems. One said that they were taking part in a bowling competition in Pontefract at the weekend. The registered manager showed an awareness of the rights of people living at the home to enter into relationships and the need to be sensitive to issues of consent. Staff related well to people at the visit, respecting their choices. Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 12 Everyone who returned a survey said that they were treated well and that their privacy was respected. Written surveys from relatives said that the service supported people to live the lives they chose. One said that the service “helps my sister to help herself” and another that their relative was treated “with respect, provides a safe and stimulating environment in which to live.” They spoke of the anxiety over the future of the service and felt that communication by the organisation about this could be improved. Individual bedrooms can be locked for privacy. Systems are in place so that visitors to the home are known and so that staff know who is on the premises at any given time. People have access to most areas of the home including the kitchen and laundry so that they can make a drink and do their own washing. Lunch was seen being prepared and served for those people in the building. Choice of food was available and people helped themselves to second helpings. Written surveys from people said they liked the food served at the home. The main meal of the day is served in the early evening when people return from day services and activities. Service of this meal was also seen before the inspector left. Both meals looked and smelt appetising. People were unhurried in eating and staff were attentive to people’s needs. The dining area is spacious and is pleasantly furnished and decorated. People sat where they wished during meals. Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience good quality outcomes in this area. People can be assured that their health care needs will be recognised and addressed and that any care provided will be sensitive to their own preferences. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Written surveys from people said that they felt well cared for. The way in which care is given reflects individual choices. For instance, notes seen on care records made by a male carer showed that a resident had asked for a female carer. It was recorded that the male carer immediately sought a female carer to attend to the person’s needs. The building has level access suitable for wheelchair users and has equipment so that people can be independent in personal care or can be safely assisted by staff. Care records showed where people had medical optical and dental appointments. One person had broken her wrist and said that staff had been with her to the hospital and follow up clinic visits. Another record showed the management of a person’s skin and the attention from staff which this required. A written survey from health care professional said that the service Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 14 “always seek advice about client issues” and “advice and guidelines given are always followed”. Another said “sometimes communication of advice could be more consistent”. Medication is supplied in a monitored dosage system which is blister- packed and labelled for each person. The system has been adapted to provide safe medication practice when a person who needs medication is out of the home. This was seen in practice when medication was being prepared with a copy of the recording chart so that the records would show all medication given. Good systems are in place to ensure the safe receipt storage handling and disposal of medication. Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. People have access to information if they wish to make a complaint and are protected by the awareness of staff of potential abuse. However some people expressed dissatisfaction with the process. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Written surveys from people all said that they knew who to speak to if they were not happy about their service. The manager said that one complaint was currently being investigated. This had been referred to the person’s care manager to investigate. The complaints procedure is available to people living at the home and visitors, and is displayed so that people can access the information. The majority of relatives surveys said that they knew how to make a complaint if needed, though one said “I have never been given any instruction regarding complaints etc. I usually ring up or visit the care home. Not always popular I’m afraid, but generally it works out right in the end”. After making a complaint, another said “it becomes very time consuming and difficult. We have attempted to do it on more than one occasion without much success.” A record of complaints is kept at the home. A policy on how the service aims to protect vulnerable people is in place and a whistle blowing policy is in place so that staff can disclose poor practice without fear of being victimised. A copy of the local authority’s policy for the Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 16 protection of adults is available at the home so that the manager and staff can take proper action if an abuse is alleged or suspected. People are protected by the system for handling their money which details all income and expenditure. Two of these records were seen and monies checked by staff tallied with the record. Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. People live in a safe and comfortable environment. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: General areas of the home were seen and some bedrooms, bathroom, toilet kitchen and laundry facilities. The home has level access and is accessible for people who use wheelchairs or walking aids. The building has bathroom and toilet facilities which are fitted with specialised baths. From the outside, the appearance of Charles Court is in keeping with surrounding properties. Inside the home is spacious and has communal accommodation of open plan sitting and dining areas which can also be used flexibly when needed. Decoration and furnishing is in keeping with the age of the building and suitable to the age group of people living there. One person said they had chosen the wall colour when their room was redecorated. Outside space is level and provides a safe and sheltered place to sit in warmer weather. All areas of the home seen were clean and fresh smelling. The Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 18 home was well ventilated and airy. The floor covering seen in two toilets had surface staining. The home’s laundry was being used by people who live at the home. The laundry has washable floor and wall surfaces so that any risk of cross infection can be eliminated. The home complies with fire and environmental health regulations to make sure that it is a safe place in which to live. Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 People who use the service experience good quality outcomes in this area. Staff are trained, skilled and in sufficient numbers to support people who use the service although some people felt they would benefit from more one to one time. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Staff rotas given at the inspection showed the staffing levels and the deployment of staff being in sufficient numbers to deal with times of high demand and to give support to individual service users. Staff were seen spending time with service users or working alongside service users on tasks within the home. One person was out with a member of staff on a one to one basis. People said that staff spent time with them and this was confirmed by observation during the visit to the service. Relatives commented that they thought the service could improve by “trying to give more one to one quality time”. Others said that the service “provides caring staff, but not enough” “more one to one support would be nice”. A health care professional commented that the service “provide a good level of care support for people with learning disabilities.” Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 20 A staff training programme is in place so that staff can develop their skills and improve their practice. This showed mandatory health and safety topics and subjects pertinent to their work with adults, such as training on the implications of the new Mental Capacity Act. Pre inspection information supplied showed that eight one per cent care staff have achieved NVQ Level 2 in care. Fire training for staff is usually carried out during supervision, however the manager said that supervision has not been as regular as usual. Written surveys said that people felt well cared for and that staff treated them well. Staff were warm and were seen relating to people in a respectful and friendly way. A high proportion of staff have worked at the home for a number of years, which provides stability and continuity for the people living there. The organisation employs its own bank staff who work at the home on a casual basis and are known by people who live there. A relatives survey said “ the staff are caring and do a good job”. Recruitment practices were checked by looking at staff records, which showed that any potential member of staff must make written application giving details of their past employment, two written references and a criminal records disclosure are taken up and a face to face interview takes place prior to appointment. In one instance, the two given references had been taken up but the applicant had recent relevant experience in working with people with learning disabilities and no reference had been sought from this source. Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience good quality outcomes in this area. The home is managed well and people who live in the home have a say about how the home is run, but there are no formal means of identifying potential improvements to the service. Further attention is needed to documentation and staff training with regard to fire safety. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The manager Anthony Egan is registered under the Care Standards Act,. He has worked at the home since May 2003 and has experience in working with adults with learning disabilities. He demonstrated an in depth knowledge of people living at Charles Court and their needs, and the issues which present themselves when caring for people with learning disabilities, such as maintaining the balance between living a fulfilled life with the need to take risk. There are established management arrangements at the home, which is Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 22 supported by senior staff in the organisation who visit to provide the manager’s supervision and to check on the operation of the home. The manager is supported by the deputy home manager Louise Slater, who is undertaking the Registered Managers Award and senior support staff. Several people living at the home and relatives comments received expressed anxiety about the future of the service. The manager explained that the organisation is undertaking a review of all its residential services which is being conducted by a partner organisation and a seconded care manager from the local authority. He said that the review will take time to complete as each person using a service will be consulted about their needs and any change. One relative said about the service “at the present time it meets her and my needs. It is the future proposed changes of which we the relatives know very little that gives us anxiety and worry.” People living at the home have opportunities to comment on their service and influence the way it is provided by regular residents’ meeting. The manager said that staff meetings are timed to follow the residents’ meetings so that any issues can be addressed quickly. Care records confirmed that peoples’ choices are recognised and acted upon. There is a formal quality assurance system in place within the organisation in which each manager annually audits their own service and this is checked by a “peer review” where another manager visits to verify the findings. The document produced by the manager was dated 2004 and had not been verified or “signed off” by a senior manager. Monthly visits are made by a manager within the organisation to check on the operation of the home. People who live in the home were told about the forthcoming inspection and one person volunteered to help with the distribution, collection and return of surveys. A sample of the health and safety records were seen. These were:● ● ● ● ● Hot water temperature checks Servicing records for hoisting equipment Safety tests on portable electrical appliances Gas Safety certification dated 8th May 2007 Electrical Installation certification dated 18th July 2002. This certificate was due to be renewed on 18th July 2007. Contractors had completed the check on 25th June 2007 and a new certificate is awaited. The home’s fire records were also seen and showed that fire detection and fighting equipment are maintained in good order. Annual fire training is provided for all staff by an outside company and a fire evacuation of the building had been carried out. However other staff fire training was not up to date. The manager said that this was covered on induction training for new staff and in formal supervision, but that supervision had not been given regularly. The manager said he had a copy of the North Yorkshire Fire Risk Assessment document but had not yet made and recorded the assessment. Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 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 Standard No Score 1 X 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 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 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 1 X X 2 X Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA39 Regulation 24 Requirement A quality assurance system based on the views of people living at the home and their representatives must be put in place so that the service can be improved to the benefit of those living there. A fire risk assessment must be completed in consultation with the fire officer. Staff must receive regular periods of fire training identified in the fire risk assessment so people know what to do in the event of a fire. Timescale for action 30/09/07 2 YA42 23(4) 31/07/07 Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 25 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 YA6 Good Practice Recommendations Care plans should be drawn up with the involvement of the person and signed by them or their representative if possible. Consideration should be given to each person holding their own care plan. 2 YA22 The organisation should consider how effective the complaints procedure is for people who live at the home, their relatives or representatives, and make any improvements so that any complaint can be addressed openly and efficiently. Additional references should be sought from previous employers where these are relevant to the post being offered. 3 YA34 Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Charles Court DS0000015792.V335856.R01.S.doc Version 5.2 Page 27 - 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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