Inspection on 04/01/06 for Colne House

This inspection was carried out on 4th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Colne House 15/08/07

Colne House 16/05/07

Colne House 23/05/06

Colne House 08/09/05

Colne House 22/03/05

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 Colne House 22 Manchester Road Slaithwaite Huddersfield West Yorkshire HD7 5HH Lead Inspector Alison McCabe Unannounced Inspection 4th January 2006 3.15pm Colne House DS0000062797.V271258.R01.S.doc Version 5.1 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 Colne House DS0000062797.V271258.R01.S.doc Version 5.1 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. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Colne House Address 22 Manchester Road Slaithwaite Huddersfield West Yorkshire HD7 5HH 01484 844775 01484 844775 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) Bridgewood Trust Limited Mrs Eileen Field Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8) of places Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. New admissions into the home should be for service users with a learning disability who are under 65 years. 8th September 2005 Date of last inspection Brief Description of the Service: Colne House is registered to provide accommodation and personal care for up to eight adults with learning disabilities. The home was taken over by the Bridgewood Trust in December 2004. The Bridgewood Trust is a local voluntary organisation providing a range of services to people with learning disabilities. Colne House is a substantial stone-built, three storey detached property set in its own grounds on the outskirts of Slaithwaite, a pennine suburb of Huddersfield. Access to the property is via steps and a steep driveway. Parking is available to the rear of the property. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted between 3.15pm and 7.45pm. The inspector had the opportunity to talk to service users, staff and the registered manager. All the service users except one went out for the evening to a Christmas event arranged by the local Rotary Club. Service user, staff and maintenance records were also examined as part of this inspection. It is positive that, since the last inspection, some improvements have been made to the premises in order to make the home more accessible to service users with physical disabilities. The inspector has been advised that further changes to the premises are to be made, however the CSCI have not yet been formally notified of these proposals. It was disappointing that none of the requirements made at the last inspection had been met in full and none of the recommendations had been implemented. All requirements and recommendations have therefore been repeated in addition to those identified at this inspection. What the service does well: What has improved since the last inspection? Doorframes to the lounge and dining room have been widened so that service users using wheelchairs can access these areas. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 6 Ceiling tracks and hoisting equipment have been installed in one of the service user’s bedrooms. An external lift is in the process of being installed so that service users with physical disabilities can access the home safely. 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. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 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 Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed on this occasion. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Residents’ care plans fail to fully meet all their health and welfare needs. Identified risks to residents have not been assessed appropriately. Service users are supported to make decisions. EVIDENCE: Individual care plans and risk assessments for three service users were examined as part of this inspection. It was concerning to note that there had been no progress in this area since the last inspection. Care plans fail to address service users’ assessed needs. For example, there was no information concerning a service user’s dietary requirements despite this being identified as a need. Following the last inspection, fluid balance charts had been kept for a short time, however these had not been maintained and information recorded was insufficient for effective monitoring. A nutritional assessment had been completed for a service user, however there was no record of the service user’s weight. Staff reported that a judgement was made as to whether the service user had put on or lost weight by how her clothes fit. This is Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 10 unacceptable and it is a requirement that adequate arrangements be made to monitor the service user’s weight appropriately. The inspector was concerned to find that moving and handling equipment installed for a service user was not being used appropriately and staff were lifting the service user manually rather than using the equipment provided. There was no care plan or moving and handling assessment in place regarding how to support the service user with moving and personal care. The current care planning tool is a combined care plan/risk assessment. Action plans are then developed from this. The organisation has identified that this does not adequately address all areas required and have introduced a revised system. No progress has been made in implementing the revised system into this home. The manager reported that the organisation had agreed a deadline for these to be completed by the end of February. Action plans are reviewed weekly, with staff recording progress in achieving agreed actions. It was noted that many of the service users have the same aims and that there was little evidence that these had been achieved. Action plans from 1st August to 31st December were examined. The aims remained the same for the whole period looked at. It was concerning to find that one service user’s three identified aims had not been achieved despite some of the aims being fairly modest; to write to his family, continue on life book, go on a train. In the records covering the five-month period, there was evidence that the service user had been supported to go on a train on one occasion and no evidence that the other aims had been achieved. The manager said that it was a case of staff not recording accurately rather than the aims not being met. Identified risks to service users had not been assessed adequately and a requirement has been made regarding this matter. It is important that agreed actions to minimize risks to service users are documented and implemented. Daily records are not kept and it is recommended that this be introduced to evidence whether or not residents’ identified needs have been met. This was recommended at the previous inspection. The inspector observed some examples of service users being supported to make decisions, for example, a service user was asked where she would like to have her meal. Service users were offered a choice of snacks. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15,16,17 Good support is offered to service users to maintain contact with family and friends. Evidence does not indicate that service users are offered a nutritionally balanced diet. Monitoring of service users’ nutritional needs is unsatisfactory at this home. EVIDENCE: Through discussion with service users and staff, and examination of records, there was evidence that service users are supported to maintain contact with family and friends. Service users are supported to receive visitors at the home; the ex-manager from the home visited during the inspection. A Christmas party was held at the home and relatives and friends of service users were invited. Service users have unrestricted access to all parts of the home with the exception of the office and laundry areas. Staff were observed to interact with service users some of the time, however there were times during the inspection where staff interacted exclusively with each other. Service users’ Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 12 preferred form of address is not recorded within the individual plans and it is recommended that this be added. Menus were examined along with food supplies. Staff said that they write the menu and do the shopping; service users do not participate in this. It is recommended that residents be offered the opportunity to plan, prepare and serve meals if they choose to do so. Menus examined did not demonstrate that a nutritionally balanced diet is offered to service users. There was little evidence that vegetables and fruit are offered and fruit and vegetable supplies were low. A requirement was made at the previous inspection that records of food were to be improved but this has not been complied with. The service manager reported that appropriate recording charts had been devised for this purpose, however these have not been completed as required. A service user’s care plan states that snacks and drinks must be offered hourly, however staff spoken to were unaware of this and there was no evidence to suggest that this had been implemented. Staff reported that the service user was offered food/drinks at the same time as the other service users. Records of food were poor and, where risks had been identified regarding nutrition, monitoring was inadequate, not in line with advice from professionals and not in line with the agreed care plan. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Service users’ health and personal care needs are not always met. Medicine management at this home needs to improve. EVIDENCE: More detailed information about how residents prefer to be supported with their personal care and moving and handling needs to be recorded; this was raised at the previous inspection. Since the last inspection, tracking has been installed in the ground floor bedroom and new hoisting equipment purchased. There is now tracking in both the bedroom and en-suite bathroom for a service user with mobility difficulties. Through discussion with care staff it was apparent that the equipment is not being used as intended. The current arrangement requires staff to unclip the hoist from the track in the bathroom or bedroom and reattach it in the room that it is required, as the tracking does not run between the two areas. A member of staff attempted to demonstrate this procedure, however was unable to unclip the hoist using the pole provided. The hoist is very heavy and poses risks to staff in clipping and unclipping it from the overhead tracking; a risk assessment must be completed considering the identified risks. Staff reported that due to the difficulties in using the equipment, staff lift the service user out of bed, onto the commode, and into Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 14 her wheelchair. The inspector observed staff lifting the service user and was concerned that staff are drag lifting. This practice is unsafe and may cause injury and pain to the service user. Since the last inspection, an Occupational Therapist has completed an assessment with a service user at the home. Advice within the OT report was not followed during the inspection. The report states that, when transporting the service user in a wheelchair, the safety belt and footplates must be used. A turntable and handling belt were to be used when staff were transferring the service user from her wheelchair to chair in the sitting room. None of this advice was observed to be followed; the service user was tipped backwards in the wheelchair to avoid her feet dragging on the floor when she was moved. It is essential that moving and handling practice be reviewed and professional advice adhered to. Records examined demonstrated that service users are supported to attend healthcare appointments and referrals are made to appropriate specialists. As previously mentioned however, advice given by appropriate specialists is not always adhered to and this must be addressed. Medicine management was assessed at this inspection. Staff have received appropriate training provided by ‘Boots’ and the home uses the Boots monitored dose system. Medication examined did not reconcile with records kept and changes to administration instructions were not always clear. There was no recorded date of opening on a medicine that was to be discarded four weeks after opening, and there was evidence that the medicine had been given after the recommended four weeks. This was discussed with the member of staff at the time of inspection. Errors in medication records were also identified at the last inspection and progress must be made in this area. During a tour of a service user’s bedroom and en-suite bathroom, the inspector was concerned to find creams prescribed for another service user and a staff member in the bathroom cabinet. The staff member was unsure if these had been used on the service user. It is not acceptable to use creams prescribed for specific service users on anyone other than the person named on the label. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Adequate policies and procedures are in place to protect service users from abuse. EVIDENCE: A satisfactory adult protection procedure is in place, and staff have received training in this area. A copy of the Kirklees multi-agency guidelines was available in the home. Staff knew where they could find the procedure should it need to be implemented and were able to describe some elements of the procedure to the inspector. Care needs to be taken to ensure that service users are cared for in accordance with advice and instructions from appropriate specialists. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,28,29 Service users live in a comfortable home with plenty of communal space. The home is not entirely suitable for service users with physical disabilities. EVIDENCE: The communal areas and the bedroom on the ground floor were seen as part of this inspection. It is positive that the provider has taken some steps to adapt the environment to make it suitable for service users with physical disabilities. At the time of the visit, builders were in the process of installing an external lift to enable service users with mobility difficulties to safely access the home. As previously discussed in this report, tracking and hoisting equipment have been installed in the ground floor bedroom and en-suite bathroom as a temporary measure. The manager explained that the longer-term plan is to renovate what used to be the previous owner’s flat, situated on the ground floor, into a bedroom with adapted bathroom for the service user with a physical disability. A second self-contained flat that was also used by the previous owner is situated on the second floor of the building. Service users do not currently access either of the two flats as they do not comply with fire regulations, however there are plans to renovate both so that the service users can use them. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 17 The CSCI has not yet received any proposals from the provider outlining the planned refurbishment of the property and timescales and this is required once again. Although tracking for a hoist has been installed, staff have experienced difficulty in using this equipment, as the track does not go from the bedroom directly to the bathroom. Staff reported that there is insufficient space to support the service user to use the sink and toilet, therefore a commode and bowl continue to be used in the service user’s bedroom. The other downstairs toilet is also inaccessible to service users with mobility difficulties. Staff are now able to support the service user to access the bath, which is positive, although the bath is low and only accessible on one side. The doorframes into the lounge and dining room have been widened so that service users requiring wheelchairs can access these areas. Although most areas of the home seen were found to be clean and tidy, it was noted that the ground floor bedroom needed cleaning, the commode and bedding in the ground floor bedroom were soiled and a chair specifically for use by one service user was soiled and parts were damaged. There is plenty of communal space at this home, including a good-sized lounge, separate dining room and a large activities’ room in the basement. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 Relevant training is provided to staff although the majority of staff are not appropriately qualified to NVQ level two or above. Staffing levels are adequate to meet the needs of the service users most of the time. Good recruitment practice and procedures are in place. EVIDENCE: Some positive care practice was observed where service users were offered choices and spoken to with respect, however some examples of negative care practices were observed, for example, service users not being informed prior to staff moving and handling them and staff not always interacting with service users in a positive manner. Although staff spent some time with service users when they were offering drinks, snacks etc, there were lengthy periods of time when most of the service users were left unsupervised in the lounge. Of ten care staff working at the home, one holds an NVQ level 3 in care and two hold NVQ level 2 in care. The manager reported that one staff member has submitted her work for verification and therefore should have her certificate in level 2 soon. One other member of the care team is registered to do NVQ level 2. Three staff are completing the LDAF induction and foundation training. In order to meet standard 32 of the National Minimum Standards, 50 of care staff need to achieve NVQ level 2 or above. There is a Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 19 comprehensive training and development plan in place. Staff have received training in health and safety, movement and handling, food hygiene, fire safety, Boots advanced medication course, and breakaway techniques. This is in addition to NVQ training which is ongoing. Since the last inspection, two staff have left the home and a new night staff and domestic have been employed, both of whom are on induction training. Upon examination of the rota, it was noted that on most days there are short periods of time (around an hour) where only one staff member is on duty. Given that it has been identified that a service user accommodated at the home requires two staff for transfers and support with personal care, it is essential that, at all times,there are sufficient staff available in order to meet the service users’ needs. The staff on duty must be appropriately skilled and trained to meet the service users’ needs; it is not appropriate that the second member of staff is the domestic as was described to the inspector. This was discussed with the manager at the time of inspection. Recruitment records were seen and found to contain the required information with the exception of some staff that have worked at the home for many years, prior to Bridgewood Trust taking over. CRB checks were seen for all staff working at the home. A health declaration form and a form explaining any gaps in employment has been completed by all staff, including those who have worked at the home for years. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42 An experienced manager runs the home. Good quality assurance systems are in place at this home. The health, safety and welfare of service users and staff are not adequately protected in all areas. EVIDENCE: The registered manager has significant management experience and experience of working with people with learning disabilities. The manager is qualified to NVQ levels 2 and 3 in care and is currently working towards the Registered Managers Award. Although no units have been signed off as yet, the manager reported that she has completed most units and has three remaining. The registered manager undertakes regular training in order to update her knowledge and skills. The manager said that there is often insufficient time for her to complete all her management tasks in addition to working on shift and completing the Registered Managers Award. This should be addressed by the organisation. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 21 The organisation uses the ISO 9000 quality assurance system. In addition to this formal system, feedback is sought from service users through resident meetings and service user questionnaires that are completed prior to individuals’ annual reviews. The views of family, friends and stakeholders are also sought during the review process. Records required by regulation are not all current and complete. This has been discussed under standards 6,9 and 18. Records regarding health and safety matters were in good order. There was evidence in the records that most of the required checks and maintenance of safety equipment is carried out. Fire alarm tests are not always conducted weekly and this matter was raised at the previous inspection. Since the last inspection, a record of which alarm point tested has been kept, however there is no planned system to ensure that all points are tested in rotation; some are tested more frequently than others. As mentioned previously in this report, unsafe movement and handling practice was observed during the inspection. The practice of drag lifting service users and tipping service users back in wheelchairs must stop in order to protect their health and safety. Appropriate equipment must be used when moving and handling service users. It is recommended that a risk assessment be completed in relation to staff unhooking heavy hoisting equipment from the installed ceiling tracking. Moving and handling risk assessments in respect of service users must also be completed. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 22 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 X 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 X 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 1 28 1 29 1 30 X STAFFING Standard No Score 31 X 32 2 33 1 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 2 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 1 X 2 X 3 X 1 1 X Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 23 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 YA6 YA18 Regulation 15 Requirement The registered person shall prepare a written plan as to how the residents needs in respect of his health and welfare are to be met. 31/10/05 unmet. Unnecessary risks to the health or safety of residents are identified, and so far as possible eliminated. 31/10/05 unmet. A record must be kept of all food provided to residents; vegetables and fruit must also be recorded when provided. Food provided must be wholesome and nutritious. 30/09/05 unmet Accurate records in respect of medication must be kept. Medication must be stored securely. 30/09/05 unmet. The registered person shall having regard to the number and needs of the residents ensure that the physical design and layout of the premises to be used as the care home meet the needs of the service users, and the size and layout DS0000062797.V271258.R01.S.doc Timescale for action 28/02/06 2. YA9 13 28/02/06 3. YA17 16(2i) 17(2) S4(13) 27/01/06 4. YA20 13 27/01/06 5. YA24 YA27 YA28 YA29 23(2a,f,n) 14/10/06 Colne House Version 5.1 Page 24 6. YA33 18(1)(a) 7. YA9 YA42 13(5) 8. YA6YA19YA42 13 (4)(5)(6) of rooms occupied or used by residents are suitable for their needs. Suitable adaptations must be made and necessary equipment and facilities provided to residents who are old, infirm or physically disabled. The organisation should provide an action plan with proposed timescales to the CSCI by the date shown. 31/10/05 unmet. The registered person must 27/01/06 ensure that at all times there are sufficient numbers of staff on duty to meet the health and welfare needs of the residents. 30/09/05 unmet. Suitable arrangements must be 27/01/06 made to provide a safe system for moving and handling residents. Movement and handling risk assessments must also be completed. 15/10/05 unmet. Agreed care plans must be 27/01/06 implemented as intended and advised by appropriate specialists. 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. 2. 3. 4. Refer to Standard YA6 YA41 YA9 YA17 YA42 YA32 Good Practice Recommendations Daily records should be kept to demonstrate how the individual service users needs are being met in line with their individual service user plan. Residents should be offered the opportunity to participate in the planning, preparation and serving of food taking into account individual risk assessments. The fire alarm should be tested every week. Staff should continue working towards achieving NVQ level DS0000062797.V271258.R01.S.doc Version 5.1 Page 25 Colne House 5. YA37 2 or above. 50 of care staff should be qualified to NVQ level 2. The registered manager should continue working towards achieving the Registered Managers Award. Colne House DS0000062797.V271258.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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