Inspection on 23/05/06 for Dell Residential Home (Sudbury)

This inspection was carried out on 23rd May 2006.

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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dell Residential Home (Sudbury) 19/05/08

Dell Residential Home (Sudbury) 20/04/07

Dell Residential Home (Sudbury) 06/12/06

Dell Residential Home (Sudbury) 29/07/05

Dell Residential Home (Sudbury) 25/04/05

Dell Residential Home (Sudbury) 25/11/04

Dell Residential Home (Sudbury) 22/09/04

Dell Residential Home (Sudbury) 10/07/03

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

CARE HOME ADULTS 18-65 Dell Residential Home (Sudbury) Cats Lane Great Cornard Sudbury Suffolk CO10 6SF Lead Inspector Jan Davies Key Unannounced Inspection 23rd May 2006 11:30 DS0000024372.V296477.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 DS0000024372.V296477.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. DS0000024372.V296477.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dell Residential Home (Sudbury) Address Cats Lane Great Cornard Sudbury Suffolk CO10 6SF 01787 311297 01787 313385 the.dell@craegmoor.co.uik 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) Speciality Care (Rest Homes) Limited Mrs Marianne Banks Care Home 48 Category(ies) of Learning disability (48) registration, with number of places DS0000024372.V296477.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th July 2005 Brief Description of the Service: The Dell is a permanent care home for adults with a learning disability. The Dell was first registered in 1987 as a core and cluster home where small groups of service users are accommodated in bungalows, each bungalow forming a self contained unit. Over time, additional bungalows have been built to bring the home to the present capacity of 48. The current registered owners, Speciality Care (Reit) Homes Ltd, purchased the home in 1995 and have agreed that the Dell has now reached its maximum desired capacity. Craegmoor Healthcare Ltd acquired Speciality Care in March 1998. Each bungalow accommodates six service users and provides its own laundry and catering facilities, communal areas and gardens. Bungalows are grouped around a central day care facility. The main kitchen and office/administration building access to the site is by way of a private drive. The home is situated within a quiet residential area with good links to Sudbury town centre. The buildings are modern, purpose-built units and offer a high standard of accommodation. All service users have good sized private bedrooms. Fees range from £460.00 to £1210.00 weekly depending upon assessed need. DS0000024372.V296477.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a key unannounced inspection, carried out on a weekday between the hours of 11.30am and 6.00pm. The Registered Manager was present during the inspection and staff of the home fully contributed to the inspection process. The inspection involved a tour of the premises, discussions with staff and residents and the examination of all residents care plans and four staff files. The Inspector also looked at a variety of other documents including policies, procedures and medication records. This report assesses key standards and reassesses those that were not entirely met at the time of the last inspection in July. What the service does well: What has improved since the last inspection? What they could do better: The home has risk assessments in place, which cover a wide range of issues for each service user, however, they need to be revised to make them specific to the individual and not used as a generic model. Information not relevant to the service user needs to be removed. A system must be in place to ensure that all staff are aware of the content and instructions within the risk assessments. Whilst it is recognised that the home employs two domestic staff to clean the eight bungalows on a rota basis, a system for maintaining cleaning and laundry DS0000024372.V296477.R01.S.doc Version 5.2 Page 6 equipment must be implemented to maximise hygiene, washing and cleaning routines and minimise the risk of cross infection to service users. There needs to be a clear policy and procedure and training introduced for all staff, relatives and service users to know what action is taken in the event of unacceptable behaviour of a service user and that a consistent approach is taken at all times. Appropriate induction, training, support and supervision should be in place to ensure that all staff working in the home, including new employees have the competencies and skills to meet the needs of the service users. Staffing levels must be reviewed to ensure that the safety and welfare of the service users are safeguarded at all times. Security arrangements within the home must be addressed; any person visiting the home must be asked for identification and vetted by staff before entering bungalows. The visitor’s books must be signed and kept up to date. Risk assessments need to be carried out to assess the security of each bungalow and the vulnerability of each service user. 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. DS0000024372.V296477.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 DS0000024372.V296477.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5 Prospective residents can expect to have clear information available upon which to make an informed choice about whether they wish to live at the home. EVIDENCE: There was evidence that new service users had a detailed assessment of need undertaken prior to their admission. The information from this was used to develop a care plan and supported with risk assessments that were appropriate to their needs. A new resident had been admitted since the last inspection. The existing resident group are well established. From care plans, resident meeting minutes, talking with residents and daily records it was possible to check that new residents are made welcome and helped to settle in. It was possible to assess admission arrangements by tracking the process and arrangements of the recent admission and by talking with the resident’s keyworker and other staff it was possible to establish that the resident’s needs had been fully assessed on admission and that they had a chance to ‘testdrive’ the home. Records of admissions in files contained a full assessment including an appropriate risk assessment. Contracts were available for all service users placed that identified the basis on which needs were met. DS0000024372.V296477.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,10 Service users can expect to have their personal, health and social care needs identified. However the risk assessments need to be made more specific to the individual and more consistently followed. EVIDENCE: The inspector looked at ten care plans. The plans were comprehensive covering all aspects of personal, health and social care. However, some sections had not been completed, as had been the situation at the time of the last inspection in July 2005. Section 9 of one care plan stated that the key worker was to involve the service user in completing “My book and my way forward”. This was blank in one care plan and missing from another. Discussion with the manager confirmed that the feedback received about this document was that where there were communication difficulties they were based on staff judgements rather than the opinion of the service user. The manager informed the inspector that this has been raised with Craegmoor and plans are in the process of being revised to be more person-centred and ‘tailor-made’ to the needs of individual residents. DS0000024372.V296477.R01.S.doc Version 5.2 Page 10 Care plans contained detailed risk assessments for each service user, however these were blanket risk assessments that contained a lot of detailed information some of which was not relevant to the individual. All risk assessments referred to autistic spectrum disorder and the need for staff training, even though the service user was not diagnosed with this condition. During the inspection it was observed that one resident had been excluded from the lunch time meal because their ‘behaviour was disruptive to the other residents and difficult for staff to manage’. From discussion with the manager the resident’s care plan was for staff to positively encourage greater socialisation and inclusion at all communal meals. One resident had furniture and equipment removed from their room ‘because of their destructive nature’ and for their protection. This information was not recorded in their care plan as should be the case and nor was there evidence that this action had been formed as a result of a care plan review. One resident had cot sides to their bed. An appropriate advocate had not been party to this decision (taken for the protection of the resident) and the resident’s care plan did not record that this had been a care plan review decision. There was no clear policy and procedure and training in place for staff to ensure relatives and service users know what action would be taken in the event of unacceptable behaviour of a service user and that a consistent approach is taken at all times. The care plans were kept in the staff office in each bungalow; the doors were kept shut but not locked. Service users can access their care plan with assistance from staff to protect confidentiality of the other service users. In reality this has not occurred recently. DS0000024372.V296477.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 Service users can expect to be supported to take part in appropriate activities within the home and in the community and have the opportunity to mix with other adults. Service users can expect staff to support them to maintain appropriate relationships within a risk assessment framework. They cannot always have their food preferences taken into account. EVIDENCE: The atmosphere in the bungalows seen was calm and the relationships between service users and staff were observed to be relaxed friendly and inclusive. It was clear from discussions with staff and entries made in care plans that service users maintain appropriate relationships. Relatives visit the home on a regular basis. Recordings from the daily log confirmed that the home was responsible for planning and arranging day services as appropriate, attendance at social events and identifying any possible employment opportunities. DS0000024372.V296477.R01.S.doc Version 5.2 Page 12 This was being done in consultation with service users to ensure their needs identified in care plans were met. Regular reviews were held and helped to identify new opportunities while ensuring the existing arrangements remained relevant and appropriate. Menus seen confirmed that meals provided were wholesome and were planned to take account of residents’ dietary needs. A number of people living in the bungalows were spoken to and everyone who commented on the food said it was good. The inspector was present during the main meal of the day and the quality of this was good. However one resident told the inspector, in the presence of carers, that they would like ice cream as an alternative dessert but they were given the same as other residents. DS0000024372.V296477.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Residents can expect to receive personal support in the way they prefer and to have their physical and emotional health needs identified and monitored. They cannot always expect to have their prescribed medication administered correctly. EVIDENCE: Through discussions with service users and staff, and observation it was evident that service users receive the appropriate level of personal support as recorded in their care plans in an appropriate time and manner. One service user informed the inspector that they like to have a bath or a shower when they get up in the morning and that they would choose on the day. Evidence was seen in the staff office that a service user’s health needs are being monitored. This is part of a behavioural assessment requested by the service user’s doctor in relation to their food, fluid intake and behaviour. A service user spoken to described being ‘happy at the home, that they were treated well and spoken to nicely by the staff.” Another service user spoken with said, “They had lived here for a long time and liked living here.” There was no evidence on the training records that staff have received recent medication training. During the inspection medication administration sheets DS0000024372.V296477.R01.S.doc Version 5.2 Page 14 were checked in some of the bungalows. These were incorrect having comments written into the margins (that did not correspond with the prescribed instructions from the pharmacy). A signature denoted that medication had been given (for EM) at a time when no medication was required. The team leader explained that this was where the senior carer had signed to endorse the medication given and recorded above on the chart. From discussion with the manager she was unaware of why the instructions had been given in the margin of the chart and of who had written this in. DS0000024372.V296477.R01.S.doc Version 5.2 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 home has an appropriate complaints procedure in place and but residents cannot be assured that there are sufficient strategies in place to protect them from harm until all staff have completed the relevant training. EVIDENCE: The home has a complaints procedure in place and this is summarised in the Statement of Purpose and Service User Guide. It includes information on how to make a complaint and the stages and timescales of the complaints process. The complaints procedure was available but would benefit from being made available in different formats to ensure that residents could understand it. The complaints log indicated that relatives had difficulty in finding staff who should be in attendance in bungalows at all times. The manager explained that this could be because the one staff member was involved in personal care duties and couldn’t respond immediately. Complainants have contacted the Commission of Social Care Inspection about this issue, which is an on going issue for the home and needs priority attention. Staff spoken to confirmed that they had training on the protection of vulnerable adults as part of their induction. The manager confirmed that the home works within the guidelines of the Suffolk Inter Agency Policy and Procedures for the Protection of Vulnerable Adults. Records of incidents were seen during the inspection and discussed with the deputy manager. The home would benefit from a physical intervention policy to DS0000024372.V296477.R01.S.doc Version 5.2 Page 16 develop clear advice to staff trying to manage any aggressive behaviour. Training records and conversations with staff indicated that physical restraint training had taken place but not for all staff. Staff records contained evidence of appropriate recruitment checks including Criminal Record Bureau (CRB) checks. When asked residents confirmed that, most of the time, staff listen to them and help them to achieve their wishes as appropriate. DS0000024372.V296477.R01.S.doc Version 5.2 Page 17 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): 24,25,26,27,30 This judgement remains the same from the previous inspection of July 2005 that overall security arrangements must improve in order that service users can live in a safe and well-maintained environment. Systems of cleaning have improved but repairs to standard cleaning and laundry equipment must be done to ensure that service users live in a clean and hygienic environment. EVIDENCE: Concerns had been raised at the previous inspection with the manager about security, particularly about the vulnerability of service users and access to the bungalows. The inspector was able to access one of the bungalows without staff being aware. The door was open and a notice to visitors asked people to always ring the bell before entering. This does not provide adequate security. The manager showed the inspector premises risk assessments but these did not cover the issue of how an unwelcome intruder would be prevented access to bungalows. Each of the service users bedrooms are fitted with door locks, these are operated with an override master key from the out side, there is a handle on DS0000024372.V296477.R01.S.doc Version 5.2 Page 18 the inside for service users to open the door, this was demonstrated by one service user who showed the inspector their room. In general the home was found to be bright and cheerful, service users rooms were nicely presented and personalised, decorated in the style of their choosing and reflected their individuality. One service user showed the inspector their collection of dolls. The home was found to be clean and hygienic at the time of the inspection. The laundry room in bungalow 3 had a new washing machine; and had recently been electrically inspected; this was a requirement form a previous inspection but the adjoining bungalow had a broken tumble dryer and, as was the situation at the time of the last inspection, staff were having to take laundry from one site to another. DS0000024372.V296477.R01.S.doc Version 5.2 Page 19 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): 31,32,33,34,35,36 Progress has been made in the home’s recruitment procedures, however, staffing competence and levels need to be reviewed to ensure that there are sufficient trained staff on duty to meet the needs of the service users and to ensure their safety at all times of the day and night. EVIDENCE: The home has recruited several new care staff since the last inspection. Records showed that procedures had been followed and a POVA first had been obtained prior to the person commencing employment followed by satisfactory Criminal Record Bureau (CRB) check. Two satisfactory references had been obtained, and a completed application form and a work permit were evident for staff for whom this applied. The staffing rota was seen. The staffing ratio is one staff to each bungalow with two staff in number 8 due to the special needs of the service users. Each bungalow houses 6 service users. This was observed on the day of the inspection; however, a staff member was seen leaving a bungalow unattended for a short time whilst they went to assist another member of staff. The rota showed an average 8-10 staff on duty, however there were occasions when the numbers fell below this. DS0000024372.V296477.R01.S.doc Version 5.2 Page 20 Not all staff spoken with were receiving formally recorded supervision. The registered manager should ensure that all staff receive formal supervision at least 6 times a year and more regularly in line with development needs. The manager informed the inspectors that the team leader is additional to the nine staff required to staff the bungalows and would be the first person to fill in for staff sickness, appointments and breaks. The manager also confirmed that they would be available to offer support and that additional care hours have been negotiated for some service users for one – one support when accessing the local adult training centre. However, numbers reflected on the rota at times fell below nine. During the inspection the staffing levels fell below the prescribed rota when a staff member ‘phoned in sick’. Cover was provided when staff due to go off duty remained to provide minimal cover. This was a similar situation as at the time of the last inspection. DS0000024372.V296477.R01.S.doc Version 5.2 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): 37,39,41,42 To safeguard the health, safety and welfare of the service users the home’s induction programme for new staff needs to be reviewed to ensure induction training relates to the needs of the service user group. EVIDENCE: Throughout the inspection the manager’s approach and response was one of openness and honesty, and they were able to demonstrate a commitment to the service. The home’s policies and procedures were available for inspection and included health and safety codes of practice. However relevant policies were missing from this that are needed to protect the interests of service users. There was insufficient information available for staff to guide them in a professional manner with their duties. The appropriate policies have been referred to previously in the report. DS0000024372.V296477.R01.S.doc Version 5.2 Page 22 Staff spoken with and training records examined evidenced that the home ensured staff had essential health and safety training during their induction programme including Manual handling, Fire Safety, Food Hygiene and First Aid. The manager provided a staff-training matrix, which indicated that the members of staff had received induction and foundation training, however, this training did not cover all the relevant areas for the resident group living at the home. Residents care plans, daily records and minutes of residents meetings demonstrated the home’s commitment to actively seeking the views of residents. The home had also recently completed an annual quality assurance review which had included some consultation with residents, relatives / advocates, other professionals and staff. The inspector found that the Quality Assurance Review report was a general summary of achievements since the opening of the home and did not include an action plan based on the results of the review. DS0000024372.V296477.R01.S.doc Version 5.2 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 x 29 X 30 3 STAFFING Standard No Score 31 2 32 2 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 2 X 2 X 2 2 x DS0000024372.V296477.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 12.1 Requirement Timescale for action 01/07/06 2. YA9 14.2 3. YA20 13 4. YA24 23 The Registered Manager must ensure that the strategy plans in place to support a resident in the management of their challenging behaviour are more detailed so that staff can approach and respond to them safely and effectively. (This is a repeat requirement from last inspection.) The Registered Manager must 06/07/06 ensure that individual risk assessments carried out for each service user of any activities and identified unnecesary risk are specific to the individual and discussed with the service user to form part of their individual plan. (This is a repeat requirement from last inspection.) Staff who administer medicine 06/06/06 must comply with the home’s policy and procedure for the recording, handling and, administration of medicines. The tumble dryer must be 01/07/06 repaired for use of the residents of the bungalow where it is sited. DS0000024372.V296477.R01.S.doc Version 5.2 Page 25 5. YA42 13,23, 6. YA42 13,23 7. YA33 18 Policies for safeguarding the 01/07/06 welfare and security of the service users must be reviewed and premises risk assessments must cover the issue of how an unwelcome intruder would be prevented access to bungalows. (This is a repeat requirement from last inspection.) The registered individual must 01/07/06 ensure that there is a system in place to make immediate response to service users and their relatives when they need to speak to staff. The Registered Manager must 01/06/06 ensure that staffing levels are regularly reviewed to reflect service users changing needs and ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropraite for the health and welfare of the service users. 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 YA39 YA23 Good Practice Recommendations The Annual Quality Assurance Review should be developed into a process that includes a systematic cycle of planning. The home should develop a physical intervention policy to give clear advice to staff trying to manage any aggressive behaviour and physical restraint training should be available for all staff. The registered manager should ensure that all staff receive formal supervision at least 6 times a year and more regularly in line with development needs. 3. YA36 DS0000024372.V296477.R01.S.doc Version 5.2 Page 26 4. YA23 The complaints procedure should be user-friendly and residents encouraged to use this as appropriate for their ‘low-level’ complaints also. DS0000024372.V296477.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 DS0000024372.V296477.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. 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