Inspection on 07/02/06 for Cornerstone Trust

This inspection was carried out on 7th February 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cornerstone Trust 03/03/08

Cornerstone Trust 12/09/06

Cornerstone Trust 13/05/05

Cornerstone Trust 27/08/04

Cornerstone Trust 04/05/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Cornerstone Trust Thicketford Place 132 Thicketford Road Bolton Lancashire BL2 2LU Lead Inspector Kath Smethurst Unannounced Inspection 7th February 2006 11:00 Cornerstone Trust DS0000009314.V282278.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 Cornerstone Trust DS0000009314.V282278.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. Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cornerstone Trust Address Thicketford Place 132 Thicketford Road Bolton Lancashire BL2 2LU 01204 392043 01204 389940 thicketfordplace1@ntlworld.com 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) Cornerstone Trust Mr Clive Owen Olive Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 6 service users to include: up to 6 service users in the category of LD The service should at all times employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 13th May 2005 Date of last inspection Brief Description of the Service: Thicketford Place is a small care home, providing long-term support to six people with learning disabilities. A local, voluntary, Christian organisation, the Cornerstone Trust, set up the home in 1993. A group of trustees oversee its running, with the day to day management carried out by the registered manager. The home is on a main road, in a residential area in Bolton. There is good access to local buses and there are nearby shops, pubs and other local amenities within walking distance. Thicketford Place consists of a large, converted, end-terraced house. There are six, single bedrooms, one on the ground floor, four on the first floor and one on the second (attic) floor. There is a very small garden at the front of the house and an enclosed, patio garden to the rear. There is on-street parking adjacent to the home. Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over six hours during the late morning, afternoon and early evening. Two residents were home for the whole inspection, one resident returned home at lunchtime with the remaining returning later in the afternoon. Due to the majority of residents having communication difficulties time was spent observing how staff spoke to, cared and supported residents. Three support workers and the deputy manager was spoken with. Time was also spent looking at paper work and some rooms in the house. What the service does well: What has improved since the last inspection? Staff files now contain photographs so making sure the unit’s recruitment procedures remain good. The way resident’s money is looked after is better, which will help some residents to become more independent with their money. To keep the house looking attractive parts of the lounge and a bedroom have been re-decorated. New plans have been made for one resident to move to another house and live more independently and to provide an extra lounge in the home for one resident to use. Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 6 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. Cornerstone Trust DS0000009314.V282278.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 Cornerstone Trust DS0000009314.V282278.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): 2&3 The admission procedure is satisfactory and systems are in place to ensure proper assessments are completed prior to people moving in. Residents receive a good standard of care and support, however the issues surrounding the compatibility of those living together need to be addressed, in order to ensure each individuals best interest is served. EVIDENCE: There have been no new admissions since the last inspection. Four residents have lived in the home since it opened in 1993, while the other two have lived there for some years. All residents living at Thicketford Place have their care funded by Bolton Social Services and were admitted through care management arrangements. Inspection of the records of two residents care files showed a full assessment of care needs had been completed and social work assessments taken note off. Observation of care practice, examination of training records and discussions with staff relating to their work, demonstrated they had the relevant training skills and experience to meet the needs of the residents. Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 9 The long-standing issue relating to the compatibility of the residents living together as one group remains. At times there is tension between the residents due mainly to residents differing abilities and support needs. Staff fully recognise changes needed to be made and have been proactive in liaising with the local authority to find a solution. During the last inspection staff advised that two residents would be moving to another house where they would receive a domiciliary care service. These plans have now changed following further reviews with residents, relatives, staff and social workers. It has now been agreed that one resident will move to another house and live with one or two other people. They will be tenants and receive a domiciliary care service from the existing Thicketford Place staff. The remaining residents will continue living at Thicketford Place. Plans have been made to convert the downstairs office into a lounge for the exclusive use of a second resident. Staff have found this particular resident prefers to spend time away from other residents and are hopeful this will lead to a reduction of any underlying stress brought about by the group living setting. To date there is no definite timescale for this to take place, but negotiations with the local authority are continuing and it is hoped the changes will take place in the coming year. Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&7 A good care planning system is in place, which provides staff with the information and guidance they need to ensure resident’s needs are met, but staff need to make sure they are updated when there is a change in residents care as some information was not accurate. Personal support is offered in such a way as to promote residents to make decisions. Adding personal information, aspirations and goals to care plans would better reflect how staff worked hard to treat each resident as an individual and support and enable them to make choices. EVIDENCE: Two care plans were examined. The care plans contain details of resident’s family and friends, medication, pen picture, communication, health, routines, likes and dislikes and support needs. The plans were easy to read and set out clear guidance for staff to take when providing care. The care plans examined contained some very good information in respect to resident’s needs, likes/dislikes and chosen lifestyle. For example one instructed staff “I like to do my own washing and cook my own tea” and “Must not feel rushed”. Staff complete monitoring sheets examination of which gave a good indication of the care provided, any activities undertaken and residents well Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 11 being. Individual risk assessments are completed and cover individual and environmental risks. It was evident from both observing staff and residents together and from discussions that staff that they were very knowledgeable about the residents and their needs. One area staff are asked to consider is in respect to adding more information about resident’s aspiration and long and short term goals in care plans. This is relevant given that it is planned one of the residents will move to a supported living setting. Discussion with the deputy manager indicated this had been recognised and she had some very good ideas how this could be achieved. Two shortfalls were noted. One care plan indicated a resident attended day care when she did not. It was also found that one residents review took place in November 2004 and was overdue. Both these issues need to be addressed. Most of the residents have communication difficulties nevertheless within safety considerations residents are enabled to make choices. For example in regard to the decor where residents are shown pictures which they can choose from. Regular residents meetings are held and advocacy services are available. Staff are very knowledgeable about residents preferences in regard to activities, meals and preferences. During the visit staff were observed assisting residents to make choices. In the case of residents being unable to make an informed decision this is clearly documented. As previously mentioned the inclusion of more information relating to aspirations and goals will more fully reflect that residents are enabled and supported to make decisions about their lives. Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 15, 16 & 17. Residents are actively supported to lead meaningful lives within the community and maintain contact with their family and friends. Within agreed restrictions daily routines promote residents independence and individual choices. Mealtime arrangements are good offering variety, choice and interest for people living in the home. EVIDENCE: Residents take part in a varied range of social and leisure activities within the local community. These include visits to leisure centres, cinema, concerts, shopping and meals out. Good practice was noted, as staff time was regularly provided to accompany residents outside the home. Family and friends are welcome to visit the home. The only restrictions placed would be at the request of a resident or if contact was assessed as being detrimental. During the day most of the residents take part in activities outside the home so visitors are requested to contact the home before visiting. Residents in the home are fully involved in activities within the community so have the opportunity to develop friendships outside the home. For example one resident regularly goes bowling with a friend who does not live at the Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 13 home. Good practice was noted, as residents are encouraged to maintain contact with their families. One resident regularly visits her family and stays overnight. Staff were observed to respect residents privacy when entering bedrooms and bathrooms. Interactions between staff and residents were observed to be frequent and friendly. For example staff were observed spending time quality time with residents. Staff spoken with confirmed this was seen as an important aspect of their role. The daily routines within the home are flexible, with a minimum of house rules. For example the majority of the residents attend college or day centres during the week so at the weekend like a “lie in”. Mealtime arrangements are flexible enough to accommodate individual preferences and the activities residents take part in. Residents are involved in planning meals and are able to choose what they would like to eat. It was evident that very little convenience foods and healthy eating is promoted. For example on the day of the visit a good supply of fresh fruit and vegetables were in evidence and staff were observed preparing a homemade curry and Shepard’s pie for tea. Staff and residents shop for food together at local supermarkets and shops. There was evidence of special dietary needs being met. One resident has a reduced gluten diet. Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Residents’ physical health was promoted and maintained through regular monitoring and health care checks EVIDENCE: There was evidence that the residents’ health care needs are regularly monitored. Records of health related appointments are recorded in residents care files including the GP, optician, chiropodist and dentist. Good practice was noted, as “healthy eating” is encouraged. An example being when a resident expressed concerns about weight gain she was supported to attend weight watchers. Cornerstone Trust DS0000009314.V282278.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): 22 The home has a satisfactory complaints system with evidence that residents/relatives views are listened to and acted upon. EVIDENCE: The complaints procedure is available in a written format for relatives and visitors, and a pictorial version with an accompanying video for service users. A system is in place for recording complaints. The complaints log was examined to find that since the last inspection in May 2005 there were four recorded complaints/concerns. There was written evidence the complaints/concerns had been investigated including details of the steps taken to rectify the issues No formal complaints have been received by the CSCI over the past year. Cornerstone Trust DS0000009314.V282278.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 The standard of the environment within this home is good providing residents with an attractive, homely and clean place to live. EVIDENCE: Thicketford Place is comfortable, bright and welcoming. The standard of décor and furnishings is good and domestic in style. Residents had the use of a large through lounge, a kitchen and a conservatory dining room. There was also a pleasant enclosed patio garden, with a bbq, a small water feature and planted tubs. There were two staff offices and a staff sleep-in room on the first floor. Thicketford Place is an extended terraced house, the appearance does not identify it as a care home. The front door is fitted with an intercom door release system, which staff operate. Due to safety considerations, access to the kitchen is limited. A half stable door is fitted in one doorway and a raised handle fitted to another door. While the home is well maintained there was evidence of on-going improvements for example on the day of the visit one of the residents bedrooms was being redecorated. The resident had been fully involved in choosing the colour scheme. The Deputy manager advised that there were Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 17 plans to provide an additional shower room on the ground floor. This is a positive initiative as it will increase the range of bathing facilities for residents. During the last inspection it was noted that the wallpaper in the alcove seating area where one resident liked to lie was damaged. Concerns were also raised about the position of the socket in this area. Both these issues have now been addressed. The alcove has been redecorated and the socket repositioned. It was noted that the fixtures, fittings and interior of the upstairs bathroom are somewhat dated and showing signs of wear and tear. While functional it is recommended that as part of future renewal and maintenance consideration be given to refurbishing this area. It was also noted that one of the resident’s bedrooms would benefit from being decorated. The wallpaper wasn’t particularly age appropriate and was showing signs of age. Cornerstone Trust DS0000009314.V282278.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): 33, 34 & 35 Staffing levels are good in the home ensuring there is sufficient staff to meet the needs of the residents. Recruitment procedures for staff are robust which ensures people living in the home are protected. A comprehensive training programme is in place, which equips staff with the skills, and knowledge to meet residents assessed needs. EVIDENCE: Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 19 Staffing levels in the home are good. A minimum of three staff are on duty from 7am to 10am and 3pm to 10pm during the week and from 7am to 10pm at weekends. Two members of staff are on duty at night, one waking and one sleeping. Senior support workers and management provide on call cover. Discussion with the deputy manager indicated some clarity is needed in respect of when she is and isn’t contactable. While senior support workers have an on-call rota it would appear the deputy manager does not. The deputy manager has been issued with a phone by the trust for staff to contact her in the event of an emergency. However she is under the impression she has to have the phone turned on all the time. This of course is not possible given she is entitled to days off and leave. Steps need to be taken to clarify on call arrangements so staff are aware of which members of staff are available for advice and assistance. Staff spoken to indicated current staffing levels was sufficient to meet the needs of the residents. During the visit staff were observed to respond speedily to the needs of residents and also spent quality time with them. During the last inspection some minor shortfalls in recruitment records were found. For example an absence of staff photographs missing references in one staff file. Both these issues have now been satisfactorily addressed. The files of three staff employed were examined to find indicated that all necessary recruitment checks had been undertaken. Staff files examined contained: written application forms, 2 references, Criminal Records Bureau (CRB) check and verification of identification. A comprehensive staff development programme is in place and records of training are maintained. Continued good practice was found in regard to induction and ongoing training opportunities for staff. There was evidence that new staff undertake induction training that meets the Sector Skills Council targets. Staff undertake a seven day induction course organised by Bolton Social Services. Staff also shadow more experienced colleagues and were not left working alone unless they were assessed as being competent or felt confident to do so. The deputy manager had only been in post for three weeks and confirmed her induction so far had been good. Ongoing training is available and there is ample evidence that these opportunities are taken up. Staff spoken with also confirmed this. One member of staff described the training as being “Very good”. The training records of three staff were examined to find they had undertaken a good range of both mandatory and specialist training. Course completed included, managing challenging behaviour, moving and handling, health emergencies, food hygiene, continence, medication, counselling, cultural awareness, first aid, fire safety, protection of vulnerable adults and first aid. National Vocational Qualifications (NVQ) are promoted and though the exact figures were not Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 20 available the deputy manager indicated over 50 of staff had attained an NVQ. Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 The home is well managed and run efficiently providing a safe environment for people living there. The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which include seeking the views of residents, staff and relatives. EVIDENCE: Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 22 The manager was on annual leave during the visit therefore it was not possible to explore in any training he has completed. Nevertheless evidence from both this and previous inspections indicate the home is well managed. The manager is a qualified nurse (RMN, RNLD) with extensive management experience. He has made good progress in implementing many of the requirements and recommendations made during the last inspection. For example in regard to the system for looking after personal allowances. During the last inspection it was noted allowances were kept in one central tin with a float. A recommendation was made to for this to be reviewed given it could lead to residents feeling there was a “never ending supply” which could hinder the development of money management skills. The manager acted on this recommendation and resident’s monies are now being maintained individually. Staff spoken with all indicated that the manager provides clear leadership and direction. There is a clear line of accountability in the home which staff are aware of. Due to the manager being unavailable this standard will be explored in more detail during the next inspection. Effective internal and external quality assurance systems are in place such as staff and residents meetings, relative satisfaction surveys and social services reviews. The results of the last relative satisfaction surveys were examined. The surveys asked relatives their views on the food, care and support, daily living, the premises and management. The results indicated relatives were either very or mostly satisfied. The minutes of the last residents meeting were examined and provided evidence that resident’s views and opinions were sought and acted upon. For example one resident commented that the fridge was too small for all the food to be stored properly. Staff had acted on this and a new larger fridge obtained. A member of the trust visits every month. He speaks to residents and staff, looks around the home and audits records. Following the visit a written report is produced of the findings and areas that need to be improved upon. The home has a system for recording the complaints of those who don’t wish to complain formally. Residents are informed of CSCI inspections and inspection reports are available for visitors and other stakeholders to read. Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X 3 X X X X Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 24 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. 2. Standard YA6 YA6 Regulation 15 15 Requirement Care plans must be updated to reflect any changes in residents care arrangements. Reviews involving residents, family and significant professional must be undertaken at least every six months. As part of the planned programme of renewal the bedroom identified in the report must be redecorated. Details of when the deputy manager is on-call must be clarified and documented. Timescale for action 30/03/06 30/04/06 3 YA24 23 01/06/06 4. YA41 17 30/03/06 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. Refer to Standard YA6 YA24 Good Practice Recommendations Consideration should be given to adding more information in care plans of resident’s aspirations and long and shortterm goals. As part of the programme of planned renewal and maintenance consideration should be given to refurbishing DS0000009314.V282278.R01.S.doc Version 5.1 Page 25 Cornerstone Trust the bathroom and installing an additional shower. Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Cornerstone Trust DS0000009314.V282278.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!