Inspection on 09/09/08 for Conifers

This inspection was carried out on 9th September 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Conifers 21/11/06

Conifers 20/03/06

Conifers 28/09/05

Conifers 14/03/05

Conifers 06/10/04

Conifers 31/03/04

Conifers 08/01/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOME ADULTS 18-65 Conifers Harriets Farm Bungalow Church Street Bocking Braintree Essex CM7 5LH Lead Inspector Sarah Hannington Unannounced Inspection 9th September 2008 09:30 Conifers DS0000017958.V371191.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 Conifers DS0000017958.V371191.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. Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Conifers Address 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) Harriets Farm Bungalow Church Street Bocking Braintree Essex CM7 5LH 01376 550779 01376 550779 saliya@saliya2.wanadoo.co.uk Mr Upul Saliya Sumaranayake Mr Upul Saliya Sumaranayake Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2006 Brief Description of the Service: Conifers is a detached bungalow situated in a quiet residential area on the edge of Bocking village. This home accommodates 6 people who are between the ages of 18 and 65 years of age who have learning and physical disabilities. The registered owner and manager is Mr Sumaranayake. Residents’ private rooms are for single occupancy. The home has a large private and well-maintained garden at the rear of the property and ample car parking facilities at the front. There is a local shop and local transport, the centre of Braintree being only a short distance away. The home also has a mini bus, which is in use daily. As at 21st November, the manager stated the fees as being £850 per week and extras to the fees include hairdressing and toiletries. Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience Adequate quality outcomes. The unannounced site visit took six hours to complete and was carried out as part of the annual inspection programme for this home. This visit was conducted with assistance from the registered care manager/provider. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. The site visit also focused on any requirements and recommendations from the last key inspection. We looked at all of the information that we have received, or asked for since the last key inspection. Prior to the site visit the manager completed an Annual Quality Assurance Assessment (AQAA) form and forwarded it to the comission. This is a selfassessment form that registered services are required by law to complete. This form provided us with information of how well the provider feels that the service meets the needs of the people who live at Conifers care home and how the service are performing against the National Minimum Standards. On this site inspection two residents and two staff were spoken with as part of this process. Prior to this visit we sent out surveys to the home for residents and staff to express their views about the service provided and the staff team. Comments from these surveys will be included as part of this report. What the service does well: Visitors are always made to feel welcome. Relatives felt that the staff communicated with them well and kept them up-to-date with any issues concerning their relatives. Many of the residents have limited communication skills but staff interacted well by using the individual’s preferred mode of communication. The residents are well cared for and looked happy and were interested in showing me around their home. The home has a ‘Residents Charter’ in place and it specifies how individuals privacy, dignity, independence, choice and rights are to be respected. Residents living in the home are encouraged to maintain skills, as well as learn new ones. Most residents help with the, shopping and preparation and the cooking of meals. A couple of the residents are keen to help the Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 6 manager/proprietor to maintain the garden and outside areas. All residents help to wash clothes and keep their personal rooms tidy. 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. Conifers DS0000017958.V371191.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 Conifers DS0000017958.V371191.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): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clear and comprehensive assessment process assures people that their needs could be met prior to moving in their home. EVIDENCE: The manager states on the AQAA that, ‘A Statement of purpose and User guide is available. A pre-admission and medical history is always carried out. Care plans drawn up to meet individual needs and are implemented. All assessments and reviews are carried out and are recorded. ’ The home has had full occupancy for the last two years and therefore there have been no recent new admissions since the last key inspection. We looked at the information of the last two people to be admitted into the home, regarding their admission, processes used and the pre- assessments undertaken. A full pre-assessment was undertaken by the manager of the home and a full assessment from their respective Social Worker, was in place prior to any admission date. Records examined and information gained from staff and people using the service demonstrated that they were encouraged to have visits to the home before moving in. The manager has recently reviewed and rewritten the Statement of Purpose and Service Users Guide. Both these pieces of documentation give clear details to prospective residents about what they can expect. Both the service users guide and statement of purpose give a Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 9 clear account of any specialist services provided, the quality of accommodation, qualifications and experience of staff and how to make a complaint. The majority of relatives stated that they had a number of visits to the home prior to any placement being offered. They also confirmed that consultation regarding pre-admission assessments and the care plan went ahead, as well as receiving a letter confirming that the home could meet the resident individual needs. Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be confident that their identified needs will be met appropriately and that they will be able to live the lifestyle they choose. EVIDENCE: The manager states on the AQAA that, ‘Care plans provide detailed risk assessments and activity plans for each resident. Care plans provide goals for individual residents to enable choice, independence as much as possible. Care plans are reviewed regularly.We listen to our residents and respond to what we hear. We encourage them to make decisions, choice and be independent. We ensure that individuality is maintained. ’ Care plans were very informative about individual’s complex needs. Care plans examined were drawn up from a range of sources including the individuals assessment needs, reports from social workers, consultants, therapists and other professionals as appropriate. Information was detailed and comprehensive and identified the needs of the people using the service. Regular reviews of individuals care needs were also carried out and details of their changing needs were reflected in their care plans. Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 11 However although the four care plans looked at were informative, they all lacked evidence of peoples involvement such as, how they would like staff to support them in making choices. This could be related to a number of preferences such as, their preferred choice of communication, including a person’s understanding and preferred style, the choosing of daily clothes, what support is needed and wanted from staff when supporting an individual during self-care the food they wish to eat and activities they wished to do for that day from the persons point of view. Daily records were also sometimes brief, containing four lines of writing to describe how a person with complex needs had spent their entire day. Staff were able to verbally provide good detail of the support, choices and understanding they had of an individuals daily needs, even though this wasn’t always recorded appropriately. Additionally care practice observation; appeared to empower people living within the home to enable them to make choices and showed us that staff had skill when engaging with people who had complex communication needs. For example, during the day staff asked people what they would like to do, some people choose to do the shopping for food, others went to day services and some chose to carry out an activity with staff within their own home. Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be assured that they will have the opportunities for personal development and build upon their daily living skills so that they are able to lead a lifestyle that they choose. EVIDENCE: The manager states on the AQAA that, ‘we access activities that are available locally. Some residents attend Diana Golding Centre and Adult community College. Various activities and leisure are offered according to individual preference. We access local amenities such as library, cinema, shops, pub, restaurants and parks, swimming, bowling etc and trips out in mini bus. We promote independence, individual choice and freedom of movement whenever possible.’ People who lived at the service informed us that they received support from members of staff in facilitating to access outdoor activities and appointments. The home has a vehicle that is used for transporting people for activities and appointments. A weekly activity schedule is drawn up with each person, Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 13 although on a daily basis observation showed us that additional choices are given as well. Evidence was available to show us that people had good access to local colleges and community based activities. Staff reported that people use the local facilities such as, library, hairdressers, cafes and weekly clubs. Therefore a good variety of social, recreational and educational choices are facilitated for all people living at the Conifers. The manager states on the AQAA that, ‘Visitors are encouraged and welcomed at any time.’ The majority of relatives reported that they felt the staff welcomed them into the home whenever they visited and that they were kept well informed about any issues. The manager states on the AQAA that, ‘We offer a balanced diet and always present meals as attractively as possible.’ Menu plans were available which confirmed that people received a good balanced nutritious meal. The usual routine is that, although there is a weekly menu guide, all people are asked what they would like for their meals on a daily basis. However, on the odd occasion even though people have made a choice for that day, they may change their minds when the meal arrives and staff told us that if this happens, people could have an alternative meal provided. Lunchtime was observed to be a relaxed unrushed interactive environment. The food smelt good and was home cooked. A resident informed me that if a meal did not appeal to one of them, then an alternative meal would be provided. Conifers DS0000017958.V371191.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be confident that their personal care and health needs will be met. EVIDENCE: The manager states on the AQAA that, ‘Review care plans to cater for the changing needs of our residents. Encourage independence as long as possible reflecting increasing needs.’ Care Plans examined showed us that people have access to a doctor of their choice and various NHS health care services and specialists if need be. Records of any of these visits are kept and were evidenced within in people’s care files. Two residents spoken with told us that they were well looked after. Members of staff spoken with were knowledgeable of the resident’s needs, their likes and dislikes and delivered the care and support accordingly. The manager states on the AQAA that, ‘We allow our residents to be as self managing as possible with regards to self medicating. We train administering medication in house and boots give annual medication training to all staff.’ Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 15 The records for ordering, administration, storage and disposal of medicines are kept in good order and no omissions were present. All staff who administer medicines have undergone the safe administration and management of medicines training. There are regular audit checks to ensure that safe administration of medicines is in practice. Conifers DS0000017958.V371191.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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the conifers are not fully protected by the staff’s knowledge, training and understanding of safeguarding procedures or the home’s procedures for dealing with complaints. EVIDENCE: The manager states on the AQAA that, ‘No complaints have been received. Complaints procedure available and all residents have a complaints policy in symbols.’ The manager has developed a complaints policy and procedures and this is included within the statement of purpose and service users guide, in a format that is of the resident’s choice (pictorial). However this is not freely available to anyone coming into the home. Additionally there were no records of any complaints made by the residents, staff, family members or any other person involved with the service. During conversation with the manager it is apparent that any issues raised are dealt with immediately and therefore not considered to be complaints. The manager states on the AQAA that, ‘All staff have attended safe guarding training (POVA) All staff read and signed policies regarding abuse. The manager has delivered some safe guarding training to staff by means of vulnerable adults safeguarding DVD and manual provided by the local council, however discussion with staff demonstrated that this had not been robust enough and that in depth training by accessing an external training may be of benefit. This is to ensure that the staff team have a full in depth understanding Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 17 of the issues that can affect the vulnerable people they support, especially around issues such as complex needs, challenging behaviour, the use of restraint and what constitutes restraint. Recording of infringements of rights are in place, however these had not been kept updated on a regular basis. Safeguarding telephone numbers and contact names were not freely available in a communal location. Conifers DS0000017958.V371191.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People that live within this service are cared for in an environment that is homely, safe and comfortable. EVIDENCE: The manager states on the AQAA that, ‘Residents bedrooms are personally decorated. Home is comfortable and homely and provides a safe environment. All bathrooms and bedrooms have locks on doors to provide privacy and dignity. Home is kept clean and free from odours. All equipments maintained and environment kept safe.’ The home was a pleasant environment, clean, fresh with no odours. The home is accessible to all people living there and in keeping with the local community. Individual’s bedrooms were comfortable, furnished well and personalised. The rear garden was an attractive space that was accessible to all people. Apart from the communal lounge there is a second area used for people to Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 19 have time on their own. Part of this room has facilities and equipment to hold sensory sessions. However this does not appear to be in use as chairs presently block access to this area. The home does not have an on-going maintenance programme; essential maintenance was done when a problem has already arisen. Most areas were well maintained apart from a few issues such as, the downstairs carpet needs proper joining at places to avoid any trip hazards. The bowl used in the laundry room needs replacing, as it is very worn. Some of the fixtures and fittings were tired and in need of replacing and some of the décor needed upgrading. Conifers DS0000017958.V371191.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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the Conifers benefit from the care and support they receive from a competent and qualified staff team and protected by recruitment policy and practices. EVIDENCE: At present there are three care staff vacancies and the manager has employed people to fill these vacant posts and is waiting for relevant checks needed before offering them a contract of employment. Four staff recruitment records viewed contained application forms, two references obtained, criminal records bureau checks undertaken and contracts of conditions of service and job descriptions were issued to new staff. Proof of ID and photographing all but one of the staff files inspected. This practice ensures a robust recruitment procedure is followed to protect vulnerable people. Looking at induction procedures these need to be updated for any new staff, to ensure these are in line with the skills for care induction requirements. Staff spoken with confirmed that there are regular meetings, individual supervisions and hand over meetings (sharing of information) on each change over of shifts. Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 21 Staff training records, and discussion with staff and management of the home told us that basic core training such as safeguarding vulnerable adults, medication, food hygiene, fire awareness and health and safety were delivered by DVD. The only external training provided for staff is the NVQ award and in this area 77 of the staff team are trained in either the NVQ 2 or 3 qualification, which is a good achievement. However, the registered manager was not able to confirm how the effectiveness of the in house training was monitored or how staff competency was assessed overall, there was therefore no evidence that people who live at the Conifers are protected by staff knowledge acquired from the training provided. Conifers DS0000017958.V371191.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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the Conifers can be assured that their health, safety and welfare are protected by the systems and practices in place and the support they receive from a dedicated staff team. EVIDENCE: The manager states on the AQAA that, ‘Manager is a trained nurse [ E.N(MS) ] and gained NVQ4 in management and has over 30 years experience with people with learning disabilities.’ The manager is knowledgeable, has good experience of the people he works with. The manager leads by example and encourages the staff team to practice in terms of a People’s rights and empowerment. The manager is a trained nurse and has achieved the NVQ4 award. There were clear lines of accountability evident at the service; all staff members, professionals, families Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 23 and people using the service had daily contact with the registered manager/provider. The manager states on the AQAA that, ‘We ask residents, use user friendly annual QA questionnaires,residents meetings, observations to seek the views of all people who live at the Conifers, to improve the quality of the home and service that staff provide.’ The manager does ensure that there is a good Quality monitoring system in place, however results are not available to CSCI, relevant interested parties and in a format the residents can access. Quality Assurance includes views of residents and their representatives. The manager has collated this evidence and has made a plan of action recording the outcomes, which is kept, within the office. The manager works closely with other agencies and has a close working relationship with the local boroughs that he works with. Additionally all annual reviews are carried out ensuring that people who use the service are listened to and that a multi-disciplinary approach is used when supporting an individual. All statutory records were available for inspection and maintained in accordance with legislation. Records inspected were up-to-date and accurate and were held securely. There were policy and procedures in place to ensure the health, welfare and safety of people living in the service and the staff team. Regular fire drills, hot water checks and moving and handling equipment were recorded. Evidence was available to confirm that the service has insurance cover for the registered manager’s legal liabilities to employees, people using the service and third parties. Conifers DS0000017958.V371191.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 3 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 2 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 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 3 X X 3 X Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 (1)(2) Requirement Care plans should be written in a format appropriate to the needs and abilities of the people using the service so that they are actively able to contribute. Timescale for action 31/12/08 2 YA6 Sch 3 (p)(q) 3 YA23 13 (6)(7) To ensure that residents care plans evidence resident’s involvement and views have been sought and that a person centred approach is used. That any restrictions on 31/12/08 resident’s choices is clearly recorded onto a format (infringements of rights) to evidence why this is necessary to restrict a persons freedom and that the decision is clearly thought out. Safe guarding training should be 31/12/08 an in depth training course. This is to ensure that the staff team have a full in depth understanding of the issues that can affect the vulnerable people they support, especially around issues such as complex needs, challenging behaviour, the use of restraint, what constitutes restraint and Infringements of DS0000017958.V371191.R01.S.doc Version 5.2 Page 26 Conifers rights. 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 Refer to Standard YA34 YA35 YA35 Good Practice Recommendations Ensure that all staff files hold the correct identification required. This is specifically related to one staff file lacking a photograph and sufficient ID. Ensure that as well as the homes induction package that the staff induction systems follow the ‘Skills for Care sector’ criteria for the induction process. Ensure that all training is undertaken for all staff. That the registered manager to record the effectiveness of the in house training and to monitor how staff competency is overall assessed. Quality-monitoring information of residents, relative and other professionals views need to be collated. The action plan with outcomes to be kept on the premises and made available for inspection and to all other interested parties. 4 YA39 Conifers DS0000017958.V371191.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Conifers DS0000017958.V371191.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!