Inspection on 27/06/06 for Derriads

This inspection was carried out on 27th June 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

Derriads 21/01/09

Derriads 16/07/08

Derriads 01/05/07

Derriads 06/12/05

Derriads 16/06/05

Derriads 27/01/05

Derriads 15/09/04

Derriads 24/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Derriads Respite Care Home 70 Derriads Lane Chippenham Wiltshire SN14 0QL Lead Inspector Alyson Fairweather Unannounced Inspection 27th June 2006 10:00 DS0000032436.V298275.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 DS0000032436.V298275.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. DS0000032436.V298275.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derriads Address Respite Care Home 70 Derriads Lane Chippenham Wiltshire SN14 0QL 01249 652814 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) Wiltshire County Council Vacant Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places DS0000032436.V298275.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 Brief Description of the Service: Derriads is an extended bungalow situated in a quiet residential area on the outskirts of Chippenham. The home provides respite care for up to four service users at a time, who have severe physical and learning disabilities. The home is owned and managed by Wiltshire County Council. The manager and staff team also run Meadow Lodge, which is part of the Chippenham Respite Service. There is 24 -hour staff cover to provide support for service users. Derriads is an attractive home, with a large lounge and comfortable furnishings. There is a separate dining room, a kitchen and two bathrooms, one with an assisted bath. There are four single bedrooms, all with wash hand basins and ceiling tracks for hoists. To the rear of the house is a large, secluded garden which is accessible to the service users, with aromatic plants and attractive features. DS0000032436.V298275.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in June, when four service users were staying. Four members of staff were spoken to, and three families returned our written questionnaire. Derriads has been without a permanent manager for some time. The acting manager has a number of years experience of working with people with learning disabilities, and all the service users who use Derriads know her. She is currently responsible for the day to day running of both Chippenham respite services, and is supported by senior staff in both homes. The staff team work well together, but would benefit from a permanent manager. Various documents and files were examined, including care plans, health & safety procedures, risk assessments, staff training files and medication records. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? At the last inspection the home was asked to ensure that an urgent review should be held for one service user whose care plan stated that the bedroom DS0000032436.V298275.R01.S.doc Version 5.2 Page 6 door should be locked for short periods at night, to stop her from coming out of her room. Staff on duty reported that this was seldom used, as it was felt to be unnecessary. This has been done, and the lock is now no longer used. The providers of the service at Derriads, Wiltshire County Council, have improved the frequency of their visits, and are now doing this on a monthly basis. This is an important part of their responsibilities, as they are able to check that the service users who use Derriads are safe and well. The old metal frames on the dining room windows have been replaced, and service users can now enjoy using a warm room which has no condensation. 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. DS0000032436.V298275.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 DS0000032436.V298275.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): 1 and 2 Prospective service users do not have enough information to make a choice about whether they would like to stay in the home. Their needs, hopes and goals are assessed and recorded before they move in to the home for respite care so that staff know how best to support them. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both before and during the visit to the service. EVIDENCE: At the last inspection the home was asked to ensure that an up-to-date statement of purpose and service user guide was available. Whilst it was acknowledged that staff had worked on these documents, it was unfortunate that they could not be found on the day. The deputy manager has been asked to ensure that a copy of these documents is kept in the office, and is made available at all times. The old service user guide which was in place gave information about both Chippenham respite units, and it is recommended that this is separated out to reflect only the service which Derriads offers, including staffing and management arrangements and the scale of fees. The home receives an up to date community care assessment containing considerable information from the referring community care team when a new DS0000032436.V298275.R01.S.doc Version 5.2 Page 9 client is planning to have respite care. Information is also kept on file for longer standing respite guests. Family members are a source of much of the information gathered, and staff visit the family wherever possible prior to respite care being offered and collect information relating to mobility, domestic skills, accessing the community, personal care needs, communication and daytime and recreational activities. DS0000032436.V298275.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Care plans did not reflect the needs of all respite service users, and not all were in place. People are assisted where necessary to make decisions about their own lives, and are supported to risks as part of an independent lifestyle. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both before and during the visit to the service. EVIDENCE: There was a great deal of information recorded about service users. However, staff kept these records in several different ways, with no structured format to follow. One file examined, belonging to a new service user, was using assessment information from a previous placement as a care plan. Another file had information under a number of headings, but this was called “additional information”. Daily notes are written for service users about things which have happened during the day. One file examined showed that a service user had some unexplained bruising, and this had been reported to the duty care manager. However, it had not been recorded in the service user’s daily record. One staff member was under the impression that they were no longer using DS0000032436.V298275.R01.S.doc Version 5.2 Page 11 care plans. The home must make sure that all staff use the same method of recording, and that all service users have a care plan in place. Care homes are also obliged to notify the Commission for Social Care Inspection (CSCI) of any incident of this nature. Staff had failed to do so, and have been asked to make sure that this is done in future. At the last inspection it was noted that some service users used bed rails, and staff were asked to ensure that reviews were sought for those service users so that there could be multidisciplinary team agreement for their use. Two files examined showed that this had not been done, and some people were still using bed rails without written agreement. The home has been asked once again to ensure that reviews are held in relation to this subject. Service users are supported to make decisions about their own lives with guidance from the staff. Staff have been working with some of the service users for many years, and are aware of service users’ wishes. Many of the service users who attend Derriads for respite care live with their families, and the home encourages people to be as much independent as possible. Where restrictions are in place, for example to limit self harm or harm to others, this is clearly recorded and guidelines are drawn up for staff to follow Risk assessments were on file for service users, and these are reviewed regularly. One service user new to Derriads had a risk assessment on file regarding the use of a wheelchair. Other risk assessments included things like transferring from a wheelchair, eating and drinking, bathing and moving and handling. Staff place great emphasis on encouraging service users to be as independent as possible, while trying to minimise any risk to their safety. Risk assessments are done in a complicated way, and it is recommended that the home introduces a risk assessment format which is more suitable for service users with disabilities. DS0000032436.V298275.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Social and leisure activities are varied and tailored to individual need, with people choosing what they wish to do. Community facilities are used on a regular basis. Service users can have as much or as little contact with family and friends as they wish, and are encouraged and supported by staff to do so. Service users’ rights are respected and responsibilities recognised in their daily lives. They are offered a healthy diet, with their preferences taken into account. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to the service EVIDENCE: Staff at Derriads try to ensure that those who enjoy regular daytime activities when they are at home can continue to do so whilst having respite care. Some people attend clubs, college and day centres, some like swimming, going to church, trampoline and volleyball. Others like to do crafts, basic cookery or simply socialising with friends. One resident was said to have a very keen DS0000032436.V298275.R01.S.doc Version 5.2 Page 13 interest in watching football and listening to story tapes. Another enjoyed being read to. One lady who has recently been referred has no day care, and staff will stay on duty for the day until she decides what she would like to do. On weekdays, many service users prefer to stay at home in the evening, as they are busy during the day. Staff try to take service users out at weekends, although they said that this is sometimes difficult as there is only one vehicle for both respite units to use. As Derriads caters for respite service users, most already have strong links with their families. However, staff encourage and support these links, and families can visit during the respite period if they wish. Staff also visit the families to carry out regular reviews. Service users can choose when to be alone or in company, and when not to join in an activity. They have unrestricted access to the home and grounds, and can come and go as they please. Daily routines are flexible, with people choosing what they want to do when they return from day services. The menu supplied in the home is varied and nutritious, and is centred round the likes of the people staying in the home on a daily basis. Breakfast usually consists of cereal and toast, and lunch can be a cooked meal for those who wish, or a packed lunch for those who go out during the day. The main meal of the day is at supper-time, and is usually cooked by staff, as the level of need of the service users means that cooking can be difficult for them. Suggestions made by families or service users for what they would like in their lunch box are recorded so that staff know what people like. There was a good supply of fresh fruit and vegetables in the home, and juices and yoghurts were also available. Staff have records of the food likes and dislikes of all service users, and of any feeding support necessary. One service user uses a plate guard and small spoon. Diabetic diets were also available, and staff were clearly aware of the various diabetic options. DS0000032436.V298275.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Personal care needs of service users are written in care plans so that they can receive support in the way they need and prefer. Their physical and emotional health needs are met. The home’s medication policies and staff good practice in administration and recording ensure that service users are safe when their medication needs are being met. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to the service EVIDENCE: All service users have support plans for any personal care required. The information contained in them is gathered from the initial community care assessment, the home’s own assessment and staff knowledge of the service users. People have guidelines in place which say how they like to be helped to get washed and dressed, assisted with food and helped to and from bed. One family member commented that her son was “always well cared for and happy. The staff look after him well”, and another said “My son seems very happy at Derriads has various adaptations and pieces of equipment in place to help with service users’ physical needs, including hoists and wheelchairs. If the families live locally, the person’s own GP is used when needed, and local GPs are used DS0000032436.V298275.R01.S.doc Version 5.2 Page 15 Derriads”. for those who live further afield. Medical professionals are seen as and when required, and staff accompany service users to appointments. This varies according to the needs of individuals and the situations arising while having respite care. The home has good links with the local learning disability teams, which enables an effective response to any crisis periods that may arise. All service users attend reviews on a regular basis, and the care plan may be amended at this time. The home has a policy in place for all medication, and all staff have medication training when they first start work. Staff administer medication to most service users but anyone able to look after their own medication would be supported and encouraged to do so. The medication cabinet was checked and all the drugs inside were found to be correct, and records kept of when medication was given had all been signed appropriately. Staff were aware of one service user’s allergy, and this was recorded in the care plan. DS0000032436.V298275.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Service users’ views are listened to and acted on. The policies and procedures the home has in place, and the regular updates in staff training in Protection of Vulnerable Adults, ensure that residents are safeguarded from abuse and harm. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to the service. EVIDENCE: The home has a complaints procedure which outlines the steps to take if there are any complaints, and all service users get a copy of this. It also gives details of how service users and families can contact the Commission for Social Care Inspection (CSCI). A complaints book is kept in the office, and it was noted that one formal complaint had been recorded there. This complaint was seen to have been dealt with appropriately. No complaints have been received about the home by CSCI. One relative responded positively, saying “I know who I can talk to if I have any concerns”. The home has copies of the Wiltshire & Swindon booklet “No Secrets”, as well as the organisational policies and procedures on responding to allegations of abuse. A “Whistle Blowing” procedure is also available for all staff. All staff have annual vulnerable adults training, and a new member of staff was seen to have had induction training in this area. DS0000032436.V298275.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 and 30 Overall service users have a homely, comfortable environment, although it is let down by one extremely stained carpet in a service users bedroom. The home is clean and hygienic. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to the service. EVIDENCE: Derriads is an attractive bungalow, with level access throughout the home, and a ramp up to the front door. Care staff look after the general household cleaning and chores. The lounge is a large, comfortable room, and has some sensory equipment in one corner. The kitchen is bright, and cheerful, with a stable type door to the kitchen, so that service users can be safe whilst staff are occupied cooking. There is a very attractive garden, suitable for wheelchair access, with a seating area under shade and a swing for guests to use. The dining room window frames have recently been replaced, meaning that service users now can relax in a warm room with no condensation on the windows. Although the carpet in bedroom three has been cleaned several DS0000032436.V298275.R01.S.doc Version 5.2 Page 18 times, it is still badly stained, meaning that service users who come in from home for respite care have to have a dirty carpet in their room. The home must now replace this carpet in order that service users can have a clean, attractive environment when they visit. DS0000032436.V298275.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): 32, 34 and 35 Service users are supported by competent and qualified staff, although some training needs have been neglected and must be addressed. It was not possible to verify that service users are protected by the recruitment procedures used by the home. Quality in this outcome area is poor. This judgement has been made from evidence gathered both before and during the visit to the service. EVIDENCE: All new staff receive induction training, and have also started using the Learning Disability Award Framework (LDAF) to assist their training, which means that the needs of service users with learning disabilities will be more fully understood. There are currently three staff undertaking NVQ Level 3 and seven who have completed it. One has also completed the Work Place Assessor award. Staff should have mandatory training which includes medication, manual handling, first aid, food hygiene, basic health and safety and risk assessment. The training file of one recent staff member showed that she had showed only done health & safety training this year, in March 2006. There had been no food hygiene or first aid training. Staff reported difficulty accessing training from Wiltshire County Council, as courses would fill up quite quickly, DS0000032436.V298275.R01.S.doc Version 5.2 Page 20 and several other staff had been unable to have food hygiene training. The home must ensure that all staff receive their induction training as well as any updates needed. Wiltshire County Council’s employment checks usually include Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks, two written references and a medical declaration. However, when asked for the file for a new member of staff, staff were unable to provide it. They reported that all staff files were kept in Meadow Lodge, the other Chippenham respite service. This was because staff frequently worked across both services. It was therefore impossible to verify if the necessary checks and references for the new member of staff were in place, meaning that service users were potentially at risk. The home has been asked to ensure that a copy of staff files is kept ready for inspection at Derriads. DS0000032436.V298275.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 and 42 Service users benefit from a well run home, although this would be improved by the appointment of a manager. They know that their views underpin the monitoring and review of care practice. The home’s policies and procedures, and the health and safety checks carried out, mean that residents live in a safe environment. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to the service. EVIDENCE: The post of team manager has been vacant for some time. No new manager been appointed yet, although staff reported that the vacant post had been advertised internally and in the local Wiltshire paper. The acting manager has a number of years experience of working with people with learning disabilities, and all the service users who use Derriads know her. She is currently responsible for the day to day running of both Chippenham respite services, DS0000032436.V298275.R01.S.doc Version 5.2 Page 22 and is supported by senior staff in both homes. The staff team work well together, but would benefit from a permanent manager. The home has good quality assurance mechanisms in place. All families are visited on an annual basis, and other contact is made by telephone and letter. A “Friends of Derriads” group has been set up, and family and friends of service users regularly meet to give feedback on the running of the home. A questionnaire has been sent out to service users and families to ask their views, and to ask if there is anything which could be done to improve service users’ stay. One of Wiltshire County Council’s senior managers makes a regular monthly visit to the home, and writes a report of her findings. There were good health & safety records in place. The fire log was examined, and it was seen that fire alarms are checked weekly by staff, emergency lighting is checked monthly, as is fire-fighting equipment. The home’s fire extinguishers are serviced on a contractual basis, and this was done in February 2006. One staff member has been assigned the role of fire officer for the home, and fire drills are done quarterly, with details recorded of how long evacuation takes. The fridge and freezer temperatures are recorded daily, as well as the food prepared for residents. As mentioned previously, some staff have not had food hygiene training, and the home has been asked to make sure that this takes place. DS0000032436.V298275.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 1 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 1 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 32 33 34 35 36 3 X 1 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X DS0000032436.V298275.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 14 Requirement The home must have an accurate Statement of Purpose and Service User Guide in place. Comment: This is the second time this requirement has been made. The registered person must ensure that reviews are sought regarding the use of bed rails for all those people to whom it applies. Comment: This is the second time this requirement has been made. All service users must have an up to date, accurate care plan on file. All staff must all be aware of their obligation to notify CSCI of any incident affecting the wellbeing of a service user. The carpet in bedroom three must be replaced so that service users can have a clean, attractive environment. Comment: this carpet has been cleaned, but is still badly stained. DS0000032436.V298275.R01.S.doc Timescale for action 27/08/06 2. YA6 15 (2) (b) 27/08/06 3. 4. YA6 15 (1) 37 27/09/06 27/06/06 YA6 5. YA24 23 (2) (d) 27/09/06 Version 5.2 Page 25 6. 7. YA32 YA34 18 (1) (c) (i) 17 Schedule 2 All staff must receive their 27/09/06 mandatory induction training and updates where necessary. Staff records must be made 27/07/06 available for inspection in the care home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard YA1 YA6 YA9 Good Practice Recommendations The service user guide should relate specifically to the service which Derriads provides. Service users’ care plans should be kept in a consistent manner, with a similar format used for all of them. The home should introduce a risk assessment format which is more suitable for service users with disabilities. DS0000032436.V298275.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 DS0000032436.V298275.R01.S.doc Version 5.2 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!