Inspection on 25/10/06 for College House

This inspection was carried out on 25th October 2006.

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

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

Other inspections for this house

College House 20/11/07

College House 17/01/06

College House 10/08/05

College House 03/11/04

College House 25/05/04

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 College House 26 Keyberry Road Newton Abbot Devon TQ12 1BX Lead Inspector Sam Sly Unannounced Inspection 25th October 2006 09:30 College House DS0000003674.V289142.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 College House DS0000003674.V289142.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. College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service College House Address 26 Keyberry Road Newton Abbot Devon TQ12 1BX 01626 351427 01626 351437 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) The Parkview Society Mr Wayne Steven Osbond Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (12) of places College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: College House cares for adults aged 18 with a learning disability. Most residents currently are over 65 years old. The Owners are a local registered charity the Parkview Society that runs several care homes in the South Devon area. College House is a large detached bungalow in a residential area of Newton Abbot close to local amenities, and within a short walk of the bus route. The premises have a lounge with sitting area overlooking the wellmaintained gardens, which are accessible to residents. There is also a kitchen and dining room and most of the bedrooms are on the ground floor. There are two bathrooms one which is adapted, and additional toilets. The first floor is reached by stairs and has further bedrooms and the office and sleep-in rooms for staff. The weekly fee at College House is £305.22. College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place during a weekday in October. All the residents were either spoken with or observed, and discussion took place with the staff on duty and the deputy manager. All types of written records were looked and a tour of all the shared rooms and some of the bedrooms was carried out. To write this report all the records of contact the Commission has had with College House since the last inspection were looked at. The acting manager provided information too. Nine of the residents, six staff, five relatives, and four care managers returned comment cards to the Commission. All the standards that the Commission thinks are most important were looked at during the inspection process. What the service does well: What has improved since the last inspection? College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 6 Care plans were up to date and had been recently reviewed. All toxic cleaning products were locked away and fire doors were not being held open with wedges. 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. College House DS0000003674.V289142.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 College House DS0000003674.V289142.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are assessed before admission ensuring College House can provide appropriate care. EVIDENCE: All but two of the residents that returned comment cards to the Commission said they had made choices to move to College House, and had been given information before moving in. The other two residents had lived at College House for many years. During the site visit the deputy manager made a preadmission visit to a potential new resident, and discussed the plans in place, including giving specialist training, to ensure the staff could meet their needs. There had been no new residents admitted since the last Inspection, however many residents had been involved in reviews with care managers, and all those care plans examined were based on information received from care managers before admission. College House DS0000003674.V289142.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are documented, understood by staff and action is taken to make residents as independent as possible. EVIDENCE: Three resident’s care plans and risk assessments were discussed with the resident. All of the residents involved did not read, and although part of each plan was symbolised, the residents still needed their plan to be read to them and did not understand the symbolised form as parts of it were unclear. One resident said more symbols and photos would help them to understand their plan better. There was also little information in plans about resident’s communication needs, although the staff on duty understood what residents were communicating. Many residents had been involved in reviews with their care managers recently. The resident’s plans had been written in January 2006 and had received an ‘interim review’ by the registered manager in September. College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 10 However, one resident had experienced major changes in their life requiring revision to their care plan due to increased risk, and this was not reflected in their care plan, nor was there a behavioural management plan despite the residents needs requiring one to be in place. This meant staff did not have clear written guidance on how to support this resident consistently. The Commission had received a concern, since the last Inspection, about the manner in which a staff member was heard talking to this resident, and that the resident was heard to be told to go to their bedroom. Records kept about the resident’s behaviour showed that they were told to go to their bedroom sometimes after behavioural incidents, however there was no behavioural plan to show that this was agreed action, or to show how staff should support this. Each resident had goals in their care plans which when discussed with them had largely been achieved, however new goals had not been agreed; old goals were just repeated. Four care managers returned comment cards, and were satisfied with the overall care provided. One of them said, about College House, ‘they have worked hard in meeting changing needs with existing clients and are prepared to with new ones, willingly, diligently and cheerfully. Six residents who returned comment cards to the Commission said that they always make decisions about what they do each day, and three said they usually did. All residents said they can do what they want during the day, evening and weekend at College House. One resident said ‘I lay the table and empty the dish washer’. During the Inspection lots of the residents spoken with gave examples of activities they chose to do, food they chose to eat, and places they chose to go. Regular resident meetings occur, and residents said they felt able to tell speak up at these meetings and be listened to. The registered manager is Department of Work & Pensions appointee for many residents. Money handled by the registered manager and staff is done so appropriately with records kept up to date. Although the staff team had discussed and agreed that no resident was capable of handling their own finances, this decision-making was not based on a risk assessment, and there were no plans to work with residents to enable them to develop these skills. College House DS0000003674.V289142.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, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lead active interesting lives as part of the wider community. EVIDENCE: On the day of Inspection residents were in and out all day going to a craft group and a singing group, it was evident from records and discussion with residents that they were out and about in the community a great deal doing activities they enjoyed ranging from food and clothes shopping, meals out, coffee out, trips out, theatre trips, discos, concerts and clubs for people with learning disabilities. One resident said he had been to Cornwall for the day the previous weekend to Truro Cathedral, as looking at churches was of particular interest to him. Residents do not have to contribute towards the cost of transport at College House. One resident said ‘I like going out in our van’. Another said they would like more staff on duty at the weekends so that: ‘we can go out more’. The need for more staff to be able to ‘have time to sit and chat’ and ‘have more one-to-one time’ was echoed by comments from two College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 12 staff members and a relative too. However, all the people that commented felt this problem was due to lack of funding. Most residents take regular holidays. Residents talked positively about the things they did, and there was evidence that they were given choices about what to do. Whilst at home residents had a range of hobbies that were encouraged. One resident made elaborate rugs, another liked collecting books, and another collected anything to do with dolphins. Residents were encouraged to be involved in the household chores including laundry and cleaning. One resident said ‘I lay tables and empty the dishwasher’. Another said they hovered their bedroom and changed their bed every week with support from a staff member. Staff spoken with had some awareness of the issues of equality and diversity that residents face, and one member of staff gave an example of complaining at a holiday camp about problems with disabled access and another member of staff said that they were proud of fighting for a resident to have two hip replacements, which would not have been done without them challenging the Hospital. Staff had not received any equality and diversity training and were not aware of the registered provider having a specific policy. Contact with family and friends are encouraged at College House, and many residents receive visitors regularly and visit or go out with family too. Five relatives returned comment cards and all said they were made welcome, were kept informed about their resident and were satisfied with the overall care provided. One relative said ‘whenever I call everyone seems happy and well cared for, everyone is most helpful.’ Another said ‘Really pleased with the Home X is really happy and stimulated by all the activities.’ Another said ‘people are very safe, clean, tidy and generally well cared for.’ The routines at College House fit around the residents needs. Staff were able to demonstrate how residents privacy and dignity is respected, and were observed during the Inspection to be respectful, friendly and approachable. All residents had locks to their bedrooms with keys provided, but some chose not to use them. Staff were interacting at all times with residents, and the Inspector shared a meal, which had a relaxed atmosphere with lots of laughing and joking between staff and residents. Particular attention had been given to arrangements for residents who did not want to eat with the others in the dining area. Residents who required support or aides to eat with were provided with them. Residents were asked what they wanted to go on the menu, and were given a choice at each meal. At the meal that was shared on the day of the Inspection one resident chose a meal, then did not want it when it arrived, they were quickly provided with a third option which they ate happily. Residents had unrestricted access to all College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 13 parts of the home, and were in and out of the office area throughout the Inspection. Residents weight is monitored regularly and two residents, who wanted to lose weight, had done so since the last Inspection. College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive support with personal and health care in ways they prefer and require and medication is administered safely. EVIDENCE: Some residents require a lot of personal care; others are more able to look after themselves with prompting and encouragement. Personal care is provided sensitively with staff receiving moving and handling training, and training on using equipment and hoists. Residents spoken with were happy with the way staff support them. Healthcare needs are well monitored and supported with records of doctor, eye, hearing, chiropody and dental checks being carried out when needed. Specialist input from the learning disabilities team is also asked for appropriately. Medication was stored safely, and records for receipt, administration and disposal were appropriate and all staff administering medication had received training. Although the medication policy included self-administration it did not promote the practice or set out a clear assessment procedure. Staff had met College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 15 and decided that none of the residents were able to self-administer their medication, however this was not based on any recorded risk assessment process and there were no goals to work towards any residents becoming more involved in the administration of their own medication. One resident was taking a particularly complex drug and some staff did not feel they had sufficient information available to feel totally confident about dealing with the possible side effects. College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse and benefit from knowing that concerns are listened to and acted on. EVIDENCE: All residents that returned comment cards were clear about whom to speak to if they were unhappy. One said ‘my key worker or a member of staff’. Residents also all said they knew how to make a complaint and one said they would go to ‘Wayne (the registered manager) or Stuart (the deputy manager).’ Residents spoke with said they felt able to talk to staff if they were unhappy, and a complaints book recorded that one complaint had been investigated since the last Inspection with action taken by the registered manager. The complaints procedure displayed at College House was in a written format, so was inaccessible to most residents, and did not hold up-to-date information. Staff spoken with were aware of the complaints and the whistle blowing procedures but could not remember reading the whistle blowing policy. . All staff had received adult protection training and an incident since the last Inspection had been dealt with appropriately by the registered manager, with specialist guidance and support brought in. Physical and verbal aggression displayed by another resident since the last Inspection had been appropriately referred to the specialist support team, and had been monitored, but no behavioural plan had been put in place and staff College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 17 had not received any additional training, although individual staff had identified this as a training need as far back as January 2006. Positive behavioural training is now booked for November 2006, but this is some ten months after it was first asked for by staff. The Commission had received a concern that was investigated as part of this Inspection with regard to the inappropriate manner with which a staff member had been heard talking to this resident. College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment at College House is homely, clean and safe for residents. EVIDENCE: A tour of all the communal rooms and about half of the bedrooms was made during the site visit. Those rooms seen were well furnished, well decorated and full of personal possessions. Resident’s artwork decorated the communal parts of the home. Residents who returned comment cards said the environment always smelled fresh, and this was the case on the day of inspection. All residents spoken with were happy with their bedrooms and proud to show them off. The home is suitably adapted for the needs of those residents with mobility needs. The ground floor is accessible to wheelchair users, and there is a hoist and adapted bath. College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 19 The maintenance person was working at College House during the visit, he said he was given a list of things to do but had to prioritise work between all the Homes owned by the registered provider. There was a maintenance book but it had not been filled in since June 2006 and a longer-term maintenance issue of repairing the flat roof appeared in several of the monthly provider reports and had been discussed at several previous inspections, however there were no records to show when this repair will take place. The environmental health department had visited in February 2006 and left recommendations that had not been implemented. The flytrap in the kitchen was full of dead flies, use of the food probe was not being recorded, and a fly screen had not been purchased. There were no records to show that the kitchen was regularly deep cleaned either. College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Enthusiastic, caring staff support residents but staff support could be improved. EVIDENCE: Six staff questionnaires were returned to the Commission and two staff were interviewed during the inspection. Three staff files were also examined. Staff were observed to be approachable, enthusiastic and interested in the residents at College House interacting at all times. Staff were receiving supervision, however, some issues identified in staff self-appraisals carried out in January 2006 had not being picked up in either supervision sessions, or in what the registered manager called ‘job chats’ since that date. Not all the staff self-appraisals had been followed up with meetings with the registered manager. One staff member had indicated a need for training on dealing with aggression due to the needs of a resident at the time, and this had not been picked up in the next supervision session. There were also suggestions about College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 21 improvements to the home, which again had not been picked up and acted on by the registered manager. Supervision records were varied in quality. A comment received from a care manager about College House staff was ‘the staff team are supportive, open and friendly.’ Two staff recruitment files held all of fitness checks and identification documents required. The most recently employed staff member’s file did not include an application form, ID or a record of an employment interview. The deputy manager was not able to say where this information was, however the application information was faxed to the Commission soon after the Inspection. The induction being undertaken by staff did not meet agreed Skills for Care standards. There was evidence of ongoing training being carried out, with all staff interviewed having done mandatory health & safety and protection of vulnerable adults training. There was a staff team training plan, however it was dated 2004 and did not show training that was identified and planned or training that had been completed. Staff said they were having fairly regular staff meetings, however records of the previous two meetings could not be found. There was not yet 50 of staff with an NVQ (National Vocational Qualification) level 2 qualifications, which is the level required for care workers. Staff commented that they felt ‘I feel College House has a good staff mix. All staff have different skills to offer, so all service users gain.’ College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Currently residents are protected but quality monitoring practices at College House are not sufficient to enable continuous improvement to the care provided. EVIDENCE: The registered manager was not present during the Inspection. The deputy manager was in charge and was able to locate most of the documents and paperwork necessary for the Inspection. Some staff that were spoken with, or who returned comment cards said that they felt supported by either the deputy manager or the registered manager. Others were not so sure. Three staff commented positively on the flexibility and personal support shown by the managers to them, who were described as College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 23 ‘very likeable and approachable’. However there were also staff comments about how residents would benefit from seeing more of the registered manager and deputy manager. There was little evidence of progress with any Quality Assurance system since the last Inspection. Residents had carried out satisfaction reports earlier in the year, however there was no evidence that their views had been used as part of the Quality Assurance system. The views of stakeholders were not being sort. The registered provider carry out monthly visits to the home, and records of these visits were examined. There was nothing recorded in the Quality Assurance folder held in the office at College House. Staff reported that they attended a range of health and safety training including moving and handling, fire safety, first aid, food hygiene and infection control. The pre-inspection questionnaire recorded that regular health & safety checks are carried out, and the records kept at College House confirmed this. A monthly risk assessment was carried out of the environment and a fire book recorded that regular fire checks and training was in place. Action had been taken to meet the requirements made by Devon Fire & Rescue service during their Inspection in August 2006. College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 2 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 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 25 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 YA9 Regulation 13 (4) (c) Requirement The registered person shall ensure that unnecessary risks to the health and safety of residents are identified and as far as possible eliminated. (A behavioural management plan should be in place with clear staff guidance for the identified resident.) The registered provider must establish and maintain a system to review and improve the quality of care at College House. Timescale for action 06/01/07 2. YA39 24 (1) 06/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 YA2 YA6 YA20 YA6 Good Practice Recommendations Residents should be included in the decision making with regard to managing their own money and medication. Decisions about residents not managing money or medication should be based on a risk assessment. Care plans and information throughout the Home should DS0000003674.V289142.R01.S.doc Version 5.2 Page 26 2. College House be in accessible to residents who do not read the written word. Care plans should also include information about residents communication needs, especially those with communication difficulties. Staff should have training on the promotion of equality and diversity and the Home should have a policy. There should be more information available for staff about the specialist health needs and complex medication used by residents. The complaints procedure should be in a format accessible to residents and hold up to date contact information. The maintenance book should be up to date with long and short-term maintenance issues. The kitchen should have a regular deep clean with records kept. The recommendations of the environmental health department report should be met. 50 of staff should have at least NVQ 2. Minutes of staff meetings should be kept. Staff should have appropriate induction and foundation training. There should be an overall staff team training plan. The registered manager should ensure that he meets with all staff that carried out self-appraisals in January 2006 and that issues identified are acted on. 3. 4. 5. 6. YA7 YA35 YA20 YA22 YA24 7. 8. YA32 YA35 9. YA36 College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 College House DS0000003674.V289142.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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