Inspection on 10/09/05 for Consterdyne

This inspection was carried out on 10th September 2005.

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

The inspector found 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 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Consterdyne 15/12/08

Consterdyne 06/12/06

Consterdyne 03/02/06

Consterdyne 11/03/05

Consterdyne 17/12/04

Consterdyne 25/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Consterdyne 6 Mason Road Kidderminster Worcs DY11 6AF Lead Inspector P Wells Unannounced Inspection 10th September 2005 02:30 Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 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 Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 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. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Consterdyne Address 6 Mason Road Kidderminster Worcs DY11 6AF 01562 69525 01562 748693 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) Worcestershire County Council Mrs Linda Joy Harradine Care Home 10 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (3), Physical disability (10) of places Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate one named person with an additional mental disorder. The home may also accommodate one named person with an additional sensory impairment. 11.03.05 Date of last inspection Brief Description of the Service: Consterdyne is a large, detached, Victorian building situated in a mainly residential area near to the ring road, approximately one mile from Kidderminster town centre. The building stands in its own grounds and is accessed by a private drive. The home is owned and operated by Worcestershire County Council and managed on a day-to-day basis by a competent and experienced manager, Mrs Linda Harradine. The responsible individual for the County Council is Mr Stephen Chandler. The home provides long-term care for 10 adults, both men and women, who have a learning disability and some degree of physical disability. Three of the service users are of retirement age. The main aim of Consterdyne is to provide a safe and comfortable home that, as far as possible, is a home for life, with staff endeavouring to meet the social, emotional, communication and health needs of all the service users. An outreach service for people with learning disabilities operates from an office adjoining the home. The office has its own separate access. The home and the outreach service have their own separate staff groups, although the outreach service is line managed by the manager of the home. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection that took place during the afternoon of Saturday, 10th September 2005. The inspector had also visited the home on 21st June 2005 for a meeting regarding the refurbishment of the kitchen. At this visit a pre-inspection questionnaire and comment cards were left with the manager who agreed to circulate the comment cards. For this inspection, time was spent preparing - reading the updated statement of purpose and service user guide, questionnaire, comment cards and monthly reports of the service manager. 3.5 hours were spent at the home. The focus of this visit was to experience the week-end routine, meet with the service users and staff on duty. Time was spent with the service users, staff, viewing the communal areas of the home, observing and reading documentation. Staff advised that service users are known as residents and this has been respected in this report. The age range of the mixed gender resident group is fifity years. Hence it is acknowledged that individuals will have differening lifestyles and needs. The inspector appreciated the co-operation and time of the service users and staff. What the service does well: Consterdyne provides a safe and secure permanent home for ten residents. The staff assist each person with their individual care and support needs. The home has a settled staff team who are experienced, trained and know the residents well. The staff are always open to advice and support from professionals and are very committed to ensuring the residents are well cared for. 7 health care professionals, 3 service users, 13 relatives and visitors returned positive comment cards indicating that they consider the service meets the individual needs of residents. Relatives/visitors commented that their resident was happy and well looked after. At the visit residents spoke positively about living at Consterdyne and the support from staff - taking them out, going on holiday or caring for them when unwell. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 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 Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 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): 1,5 The home had suitable information about the service for prospective residents, their families and representatives. The agreement needs to be introduced. EVIDENCE: The home’s statement of purpose and service user guide had been updated and copies submitted to the CSCI. The latter was in different formats. The documents indicated that Consterdyne was for residents over 45 and this needs changing because one resident is under 45. There had been no new admissions since December 2002 therefore standards 2-4 were not assessed. The home has a suitable admission procedure should a vacancy occur. The manager and clerk had produced an agreement (contract/statement of terms and conditions) for the home and it have been circulated for comments. It needs to be introduced to the service users and their representatives and then implemented. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 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): 6,9 The residents’ needs were well known to the staff and the files/plans and risk assessments need to be reviewed to give a clear, up to date record of this. EVIDENCE: A sample of the residents’ files were viewed. The files contained considerable information about the individual’s personal and healthcare needs as well as a service use plan. However the files were full with the latest information not always included in the relevant part of the file. The files needed reviewing so that the current information can be clearly and quickly accessed. It was apparent from speaking with the residents and staff that their changing needs, in particular health care needs, were known and being met. The files need to clearly evidence this in the relevant sections. Contact sheets were being kept for health and other matters. The staff need to ensure that they are recording (evidencing) in the residents’ files the good work they are doing. For example the staff advised on how that they were monitoring the food intake of service users who were not eating well/loosing weight, yet charts to evidence this could not be found on the files. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 Page 10 It was said that the residents had chosen not to retain their service user plans They were aware that the records were kept in the office and that they could read them. Reviews were taking place six monthly but it was unclear whether reviews were being held and recorded when a resident’s needs changed. The risk assessments for residents were being reviewed and found in a separate file. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 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): 11,12,13,14,15,16,17 Some of the residents attend day placements and go into town, supported by staff. The proposal to develop a variety of activities in and out of the home and for residents to be given opportunities to develop independent living skills is welcomed. The records of food provided should be more detailed. EVIDENCE: The manager and staff continue to maintain the service users’ daily living skills and provide them with a secure and homely environment where service users’ rights are respected. Two staff advised that they were planning to introduce a programme of activities in and out of the home for residents, particularly for the days when residents were did not have a day placement. Residents had been involved in discussions and were looking forward to these activities. The staff and residents had lots of ideas and some had already been introduced – a skittles evening, a few days holiday at Bridgenorth, monthly musical evening. Other activities would be most beneficial including individual resident’s independent living skills being promoted. For example regularly going out to shop for their own toiletries, going out to choose their own groceries and take away meals. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 Page 12 Some of the residents were looking forward to commencing college courses and it is hoped that transport can be arranged. Six of the residents attend day centres in Kidderminster and like to do so. One resident, who had been unwell, was looking forward to soon retuning to his day placements. During a recent week when the day centres were closed, the residents said that they had enjoyed going out for a pub meal. The residents had enjoyed a few days holiday in a cottage in nearby Bridgenorth and were looking forward to going again in October 2005. Two of the residents had also been on holiday with relatives to the seaside. All the residents were at home for the weekend and a few of the residents had been out, on the day of the visit, to the shops and for a haircut. Some residents to go into town with staff but were not using the library, leisure centre or buses. A service user had enjoyed the celebrations in house for his birthday. A new water feature, donated by a resident’s relatives, was now functioning and popular with the residents. The home’s mini bus has been out of action for some time. Taxis or staff cars are used. A few of the service users can walk to a day placement. The home would benefit from a new vehicle or booking Social Services vehicles, if there are sufficient staff to drive. The relatives/visitors commented that when they visit they are made welcome. Residents are encouraged to keep in contact with their relatives. The staff were respectful and considerate with each resident. The sample recording sheets of food provided indicated that adequate records were being kept. On the day of the visit, the residents were choosing a take away meal from the fish and chip shop, which was popular. It was said that a highlight of a weekend was the Sunday Roast. Staff advised how they were monitoring the eating and drinking of some of the residents who were frail, loosing weight or lost interest in eating (see pages 10 & 14). Also that photos of foods/meals were going to be introduced to assist residents in choosing what they would like to eat. The records of food provided need to indicate that fresh produce, in particular fruit and vegetables, are used, and that each service user is receiving a varied and nutritious diet according to their dietary needs. Staff were fully aware of the special diets/drinks of some of the residents. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 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): 18,19,21 The residents were receiving most appropriate support with their personal and health care needs from staff who knew them well. The health care records needed to be reviewed and updated. EVIDENCE: Their personal and health care needs were indicated in the service user plans. Observations and discussion with residents and staff indicated that the resident’s individual personal and health care needs were being met. Assistance with personal care was given discreetly. The hoist had been serviced, in case it was needed, and suitably located on the ground floor where the frailer residents reside. The staff group is majority female for six male and four female residents. There is one male member of staff, so when he is on duty, the male residents can be assisted by someone of the same gender. Some of the residents’ health care needs were changing and staff had ensured that professional input had been sought to assess and treat each problem. This was confirmed by the comments form the GPs and nurses. For example three commented on the ‘caring staff’. Also some of the residents said they were pleased with the support they received when unwell, going for tests and Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 Page 14 appointments. The staff were very knowledgeable about the current personal and healthcare needs of the residents. In particular the care and support for the older, frailer residents were receiving was commendable. However the residents’ plans needed to be detailed and reviewed to evidence this, as already commented upon on pages 10 & 13. The medication system was not fully inspected on this occasion. However the following was noted: An outreach service user brought his medication cassette in and it was stored in the residents’ medicines cupboard. At a previous inspection it had been agreed that the outreach service users’ medicines and records would be stored separately in the outreach office. The Home continued to use a monitored dosage system. A suitable controlled drugs register had been obtained (the home had previously installed a controlled drugs cupboard). As yet no controlled drugs have been prescribed. The deputy was booked on a medication course run by Social Services training and it was planned that she would cascade this training to the staff. It was apparent from discussions with staff that residents who become ill, age or have deteriorating conditions are suitably cared for in house under the guidance of health care professionals. The manager and some of the staff have experience and training relating to death and dying. The residents’ wishes in these circumstances had been recorded on their plans. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 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): 22,23 The parts of these standards that were assessed indicated that the home had suitable policies and procedures in place to protect service users. Staff observed, listened and responded to the service users in a positive manner. EVIDENCE: The home has complaints procedures that are in suitable formats for the residents. The pre inspection questionnaire indicated that the home had received one complaint which had been investigated within 28 days. At the visit the complaints file could not be located so this matter could not be followed up. The pre inspection questionnaire also indicated that the manager was still the appointee for 8 of the residents (previous requirement). However it was also noted that residents were receiving their full personal allowances and now had building society accounts. The records of the residents’ personal finances had been audited. The home had suitable policies and procedures to protect vulnerable adults. Some of the staff and the manager had this year attended training in protecting vulnerable adults and managing challenging behaviour. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 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): 24,28,29 The ground floor of the house was homely, comfortable, clean, safe and well maintained for the residents to live in. The rooms, space, facilities and equipment were suitable for the residents. EVIDENCE: Consterdyne is a large, detached, Victorian building situated in a mainly residential area near to the ring road, approximately one mile from Kidderminster town centre. The building stands in its own grounds and is accessed by a private drive. There are three lounges and a dining room situated on the ground floor. Also on this floor is a staff office, kitchen, outreach office, laundry, toilet and bathroom. It was this part of the home that was viewed on this occasion. The ground floor was homely, bright, clean, maintained and comfortable for the residents who were using all three lounges. The dining room furniture had been replaced and all the communal rooms decorated. The kitchen refurbishment was to commence the following week and a temporary kitchenette was going to be sited in the dining room. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 Page 17 The enclosed garden had been used by the residents during the summer and the new water feature was being enjoyed by all. The home has eight single bedrooms, two have en suite facilities. There are three single bedrooms on the ground floor occupied by older residents with mobility problems. The one double bedroom is on the first floor. It has been highlighted in previous reports that consideration should be given to extending the undersized single bedroom and providing additional single bedrooms to replace the double bedroom. There is no lift to the first floor. The first floor bathroom is due to be refurbished with a specialist bath. Also a room on the first floor had been converted into a spacious shower room for staff. Suitable aids and equipment were in place and a call bell system to assist residents with mobility problems. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 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): 31,32,33,35 The residents were being supported and cared for by a suitable number of staff, whom knew the service users well and were experienced. The staff group were suitably trained and there were opportunities for staff to attend refresher courses and further training. EVIDENCE: The home has an established, effective staff team that has not changed since 2001. This is most beneficial for the service users. The home also has a bank of relief staff and agency staff are not used. A deputy had been appointed since the last inspection and the senior post was to be filled. The home has a manager, deputy, one senior and seven support workers. Staffing details and rotas for two weeks had been submitted prior to the inspection. The inspector met individually with the deputy and the three staff on duty. All were clear about their roles and responsibilities and knew the residents well. Each member of staff confirmed that they had an NVQ in care and there were opportunities for further training in house and attending external courses. The home’s ancillary staff consist of a part-time clerk and cleaner. The vacant posts for maintenance and gardening still needed to be filled. The support workers cover catering and laundry duties as well as caring and supporting residents. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 Page 19 The staffing levels were being arranged according to the needs and number of residents at home during the day. At night there was currently two staff in the home – one awake and a second person sleeping in. The training details submitted and the discussions with staff indicated that: 50 of staff had an NVQ in care. Some staff and relief workers were undertaking the LDAF induction programme. There were assessors in house to support the staff undertaking the above courses. Updates in safe working practices were being arranged. The trainer for moving and handling had nearly completed her training and would then arrange for the manager and other staff to receive a refresher course. Infection control was being cascaded to staff by a senior member of staff who had undertaken a course. The three support workers on duty had an NVQ in care, level 3 and the deputy had commenced an NVQ, level 4. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 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): 37,39,40,41,42 This service is being run by an experienced manager who ensures that the service users’ best interests and safety are paramount. Staff would benefit from further training in some safe working practices. The fire precautions and records need addressing. EVIDENCE: None of these standards were fully assessed on this occasion. However the following was noted: The home continues to be well managed. The manager is experienced and just completed the Registered Manager’s Award. The County Council are working on a quality assurance programme. The majority of polices and procedures had been reviewed. Consideration could be given to reviewing other policies and procedures such as COSHH, hygiene and food safety, moving and handling, risk assessment and management. Records were being maintained, as required, in a care home. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 Page 21 The standard on Safe Working Practices is wide ranging and the following was noted on this occasion: The home had a variety of risk assessments for the service users and the home, which were being reviewed. Staff need refresher courses in safe working practices, particularly infection control, moving and handling. Equipment and services had received an annual service. The legionella assessment needs to be in the home and available for inspection. The recommendations (two) following the fire safety officer’s visit in April 2005 need to be implemented. The accident book was available but a recent accident of a service user had not been entered in this book. A copy of the RIDDOR form was available and CSCI had been informed of this incident. The records relating to the checks on fire safety equipment were not all up to date for the last two months. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X 2 Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X 3 3 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Consterdyne Score 3 3 X 3 Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000037401.V250254.R01.S.doc Version 5.0 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 YA5YA5 Regulation 5 Requirement The draft agreement/contract must be introduced. (timescale of 30.06.05 partially met) The registered persons must ensure that service user plans cover all aspects of personal care, health care and support as set out in Standards 2.3, 6-21 and that each aspect is kept updated. Service user plans must be reviewed immediately with service users and updated to reflect changing needs. The review of the risk assessments must be completed with new assessments undertaken if needed. The complaints file, indicating that any complaints received have been investigated, must be available for inspection. A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 39. (timescale of 30.06.05 partially met) The manager and some of the DS0000037401.V250254.R01.S.doc Timescale for action 30/11/05 2 YA6YA6 15 31/12/05 3 YA9YA9 13 30/11/05 4 YA22YA22 22 31/10/05 5 YA39YA39 24 31/12/05 6 YA42YA42 13,18 30/11/05 Page 24 Consterdyne Version 5.0 7 8 YA42YA42 YA42YA42 13,18 13,23 staff must attend a refresher course in moving and handling. The staff must receive training in infection control The recommendations in the fire safety officer’s report must be implemented. The fire records must be kept up to date. 30/11/05 31/10/05 9 YA42YA42 13,23 10/09/05 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 5 6 7 Refer to Standard YA1YA1 YA11YA11 YA12YA12 YA17YA17 YA23YA23 YA26YA26 YA33YA33 Good Practice Recommendations The statement of purpose and service user guide should accurately reflect the age group. Develop the activities as proposed. Consideration should be given to the home having a mini bus or people carrier(s) to take the service users out. Records of food provided need to be detailed to indicate service users are receiving a nutritious and varied diet according to their individual dietary needs. The manager acting as an appointee for service users should be reviewed. A review of the double bedroom arrangement and the undersized single bedroom should be undertaken. The home would benefit from ancillary staff to cover maintenance and garden duties. Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. Extracts may not be used or reproduced without the express permission of CSCI Consterdyne DS0000037401.V250254.R01.S.doc Version 5.0 Page 26 - 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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