Inspection on 15/10/05 for Downing View

This inspection was carried out on 15th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Downing View 27/01/09

Downing View 28/03/07

Downing View 27/01/06

Downing View 14/01/05

Downing View 25/05/04

Similar services:

Coopers Mill Ltd

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Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Downing View 1-3 Loring Road Dunstable Beds LU6 1DZ Lead Inspector Georgia Chimbani Unannounced Inspection 15th October 2005 09:30 Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Downing View Address 1-3 Loring Road Dunstable Beds LU6 1DZ 01582 604416 01582 670226 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) Bedfordshire County Council Mr Mark Anthony Edmunds Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. No of residents: 2 Gender: Male and female Age: 18 to 65 years Category: Learning disability Period of stay: Respite (max 6 weeks stay) Service users of 65 years. Current respite service users who are over 65 years of age may continue to receive a service from the home, as long as their needs are being met. No new service users over 65 years of age may be admitted to the home without prior consultation with the CSCI. Complete re-provision (subject to CSCI and other relevant authorities approval of the proposed plans), of the respite service by November 2005. 14 January 2005 7. Date of last inspection Brief Description of the Service: Downing View is a two bed respite service located on the outskirts of Dunstable. The accommodation and grounds are owned and maintained by Aldwyck Housing Association, with Bedfordshire County Council providing the staffing and care support. It is a condition of registration that the service will have moved and been rebuilt by November 2005 as it does not currently meet the environmental requirements of the National Minimum Standards for Younger Adults. It is hoped that the service will remain in the local area. The accommodation comprises of a small flat, which is intended to provide respite care for up to 2 adults with learning disabilities at any one time. Stays are limited to a maximum of six weeks. There are two single bedrooms, a shared kitchen, bathroom and living/dining area. The accommodation would not meet the needs of individuals with a physical disability. Community facilities and shops are a short distance from the home, which is also in easy access of local transport routes. There is ample parking to the front and rear of the property, and there is a small enclosed garden. Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on Saturday morning and lasted 3 hours and fifteen minutes. Present at the inspection were two service users and one member of staff. The inspector was able to observe and talk to service users during the course of the inspection. The inspector noted that service users appeared and relaxed and comfortable. Comment made by service users indicated that they were happy living at the home. 18 requirements were issued at the last inspection. 6 were met and 12 are restated. 10 of the restated requirements have been restated for the third time with significantly shorter timescales. The inspector is concerned at the apparent lack of compliance and the registered persons are urged to give priority to these requirements to avoid enforcement action. A further 6 requirements are issued bringing the total number of requirements following this inspection to 18. What the service does well: What has improved since the last inspection? The manager of the home is now registered with the CSCI. Recording in the accident and incident book is legible. A quality assurance exercise has been carried out to seek the views of stakeholders on the service offered by the home. The bath has been removed and a shower installed in it place. Mirrors are available in both bedrooms including the bathroom. Both bedrooms have a lampshade fitted. A mobile phone has been purchased for staff to use when they go out with service users. Downing View DS0000033029.V258676.R01.S.doc Version 5.0 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. Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The current state of the statement of purpose and the service user guide mean service users do not have sufficient information to make an informed consent about staying at the home. Pre-admission assessments ensure that the home is satisfied that it can meet the needs of service users before they are admitted. EVIDENCE: At the previous inspection a requirement was made for the statement of purpose and service user guide are revised. A statement of purpose was displayed on the wall of the office and an examination of this document revealed that it had not been revised following a requirement at the last inspection. There were no details of the qualifications and experience of the registered provider and manager, number of staff working at the home and the organisational structure. The service user guide could not be located by the member of staff on duty therefore this requirement is restated. The home is a respite unit with the main aim of providing short term stays for service users. At the time of the inspection two service users were in residence for the duration of the weekend. One of the service users had recently been assessed for regular respite. The inspector saw evidence that a full assessment of their needs had been carried out before their initial admission to the home. Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 8 The differences in the content and review of care planning documents means there is a lack of consistency in the care offered to service users. EVIDENCE: The files of the two service users present in the home were examined. Both files contained a care plan and a risk assessment however there were considerable differences in the detail of the risk assessments. The risk assessment of the newest service user was extremely detailed, covered a range of areas and was dated October 2005. In comparison, the risk assessment of the second service user covered a few areas such as accessing the community, control of substances hazardous to health [COSHH] products, sharp knives and bathing. This risk assessment was dated 1/7/04. There was no evidence of a recent review. The care plan of the same service user had last been reviewed in June of the previous year. Both care plans did not include goals nor was there evidence of involvement of the service user in the care planning process. A photograph of the service user was seen on one of the two files. This is required. The inspector received confirmation from the member of staff on duty that a mobile phone was now available for use by staff when they went out with service users. The registered persons must ensure that care plans include goals aimed at supporting individuals to maximise their Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 10 independent living skills. Care plans must be reviewed regularly and show evidence of involvement of the service user. This requirement is restated. The registered persons must ensure that risk assessments are sufficiently detailed to ensure that all aspects of the service user’s needs are covered. Risk assessments must be reviewed regularly. Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14, 16 and 17 Activities planned for service users must be recorded in consultation with them to ensure that their stay at the home is structured. The home must ensure the availability of food ingredients to ensure a high level of satisfaction among service users. EVIDENCE: The inspector noted that when service users arrive at the home, “a planning for your stay” document is completed with them. This informs the service user on the activities that they will be involved in while they are at the home. The service users at the home had moved into the home the previous day and were due to return home the following day, Sunday. The member of staff on duty was able to inform the inspector that the service users would be going out for lunch that afternoon and later they would go shopping with another member of staff. There was noticeably a lack of records relating to their planned activities as “planning for your stay” documents had not been completed for both service users for the current period of stay. The inspector was concerned that the lack of documentation might result in some activities Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 12 being overlooked when staff changed shifts. The registered persons must ensure that service users are involved in the planning of activities at the home and that their wishes and decisions are recorded. The inspector’s observations were that service users are involved in making choices regarding their daily routines. For example when the inspector arrived at the home a service user was taking a bath. The inspector observed that staff consulted them regarding any assistance they required and what they wanted to eat for breakfast. Another service user was observed making regular trips to the kitchen to pour drinks and other snacks. When staff observed that this service user was eating excessive quantities of a particular type of food, they were encouraged in a positive way to eat fresh fruit instead. The inspector inspected the kitchen found that although there were sufficient quantities of food in the home, key ingredients required for the evening meal and the following day’s lunch were not available. For example the menu stated that the evening meal on that day would be a jacket potato with baked beans and or cheese and jelly and fresh cream for dessert. The inspector confirmed that baking potatoes and fresh cream were available but there was no jelly or cheese. The next day’s lunch menu was to be roast lamb with potatoes and vegetables. An inspection of the fridge revealed that there was no lamb and when this was brought to the attention of the member of staff on duty, pork was identified as an alternative. A discussion with this member of staff revealed that where ingredients were unavailable staff could purchase these at the local corner shop. It was acknowledged that the range of foods available in the local shop was limited. Service users were observed to be enjoying their food and one service user was able to confirm this with the inspector. The registered persons must ensure the availability of food ingredients on the home so as to meet the dietary needs of service users. Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 The lack of staff medication training is poses a considerable risk to the health of service users. EVIDENCE: As the home provides respite care, the service user’s families arrange preventative health care. The inspector was satisfied that the member of staff on duty was aware of the procedure for summoning emergency health service if required. Both of the service users resident in the home were not on any prescribed medication. The medication cabinet was inspected. It contained two prescription medications for a service user whom the inspector was informed no longer came to the home. The registered persons must ensure that medication belonging to service users who are no longer living at the home is disposed of. At the previous inspection a requirement was made for the medication policy to be reviewed. The medication policy was reviewed however it was difficult to establish when it had last been reviewed as there was no date. The policy contained information on the procedures for storage, administration and disposal of medication. There was also information on the training that would be undertaken for staff but there was no reference to accredited training. The policy stated that staff training would involve reading of the medication policy and shadowing other members of staff as they undertook medication duties. An examination of the training profiles of staff Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 14 indicated that only one member of staff had medication training. The registered persons must ensure that all staff working in the home receive accredited medication training. The medication policy must be reviewed to reflect the need for accredited training for all members of staff. This requirement is restated. Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards 22 and 23 were assessed and met at the last inspection. They have not been inspected at this inspection at this inspection, however as they are key standards they will be inspected at the next inspection. Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28 and 30 There have been noticeable improvements to the bathing facilities offered at the home. Inadequate hand washing facilities pose a high risk of infection for service users. EVIDENCE: At the previous inspection requirements were made for the registered persons to provide appropriate hand washing facilities in the bathroom repair the damp in the bathroom and provide a lampshade in a bedroom. Following the last inspection the bathroom has undergone renovations. The bath was removed and a shower installed. The dampness in the bathroom had also been repaired and lampshades were available in both bedrooms. A mirror has now been installed in the bathroom as part of the bathroom cabinet. One bedroom did not have a mirror. The member of staff on duty explained that this was available but had been removed for the duration of the current service user’s stay as they would break any mirrors in the bedroom. Despite a requirement at the last inspection, there was still no hand soap in the bathroom. The member of staff no duty advised that this was kept locked away to avoid the risk of service users ingesting it. The member of staff stated that hand soap would be provided each time the service user used the toilet. During the course of the inspection service users were observed going into the toilet but Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 17 no hand soap was offered to them although the member of staff would remind them to wash their hands. This requirement is restated. Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 34 and 35 Inconsistencies in the information held on staff files calls into question the homes commitment to providing suitable staff to meet the needs of service users. EVIDENCE: At the previous inspection a requirement was made for job descriptions to be available for all staff. The member of staff on duty confirmed that they had received a copy of their job description when they commenced employment a month earlier. Discussions with this member of staff revealed that they had a full understanding of their roles and responsibilities. In the absence of management it was difficult to determine whether job descriptions were available for the respite manager and co-ordinator. This requirement is amended and restated. Staff records were available for inspection. Most of the staff working in the home are agency workers. Following an agreement with the CSCI personal profiles are maintained in the home for all staff. Original documentation is kept on file by the agency with personal profiles containing information such disclosure number, copy of a recent photograph, confirmation of proof of identity and satisfactory references. Most personal profiles contained the required information however three did not include a recent photograph. No personal profile was seen for the member of staff on duty at the time of the inspection although they started work a month ago. The registered persons Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 19 must ensure that information detailed under schedule 2 and 4 of the Care Home Regulations is available for inspection at all times. This requirement remains outstanding despite previous requirements by the CSCI. The registered persons must give priority to this issue to avoid the possibility of enforcement action. Details of staff training were recorded on staff personal profiles and on a separate training needs assessment sheet that showed courses undertaken, the review date and courses to be undertaken. There were glaring inconsistencies in the information contained in these two documents. For example the personal profile of one member of staff stated “NVQ June 2005”, it was not clear whether this was the completion or start date for this course. A number of courses such as moving and handling, first aid and food hygiene were detailed on the personal profile but these were noticeably absent from the training needs assessment. The information in the training needs assessment seemed unrelated to that contained in the personal profile. For example two courses were listed, fire safety issued in July 2003 but with no review date and Protection of Vulnerable Adults [POVA] dated July 2004 and a review date of July 2004 as well. The inspector noted that not all members of staff had a training needs assessment. Induction records were available for inspection however there was no evidence that these met the learning disability award framework. This requirement is restated. The registered person must ensure that all members of staff have an up to date training and development plan. Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 43 The findings of the quality assurance system must be fed back to all respondents to give them confidence that their views are valued. The lack of a business and financial plan does not give service users confidence in the way the home is managed. The home must work towards developing comprehensive policies and procedures to give service users and staff clear guidelines of the home’s ethos and operation. EVIDENCE: Following the last inspection, the manager Mr Mark Edmunds is now registered with the CSCI. The inspector was informed that Mr Edmunds is temporarily managing another service on the same site and in his absence Ms Mariea Merlow is managing the home. Both managers were unavailable at the time of the inspection. At the last inspection the registered persons were required to implement a quality assurance system to seek the views of service users, their relatives and other professionals. The inspector was shown completed Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 21 questionnaires but the information on the questionnaires had not been compiled into a report. The registered persons are required to compile a report of the findings of the quality assurance exercise. A copy of this report must be sent to the CSCI. The requirement for the registered individual to carry out monthly unannounced visits to the home is still outstanding. There was no evidence in the home of reports relating to these visits or of reports being sent to the CSCI on a monthly basis. This requirement is remains outstanding despite requirements from the previous two inspections. The responsible individual is required to achieve compliance to avoid the possibility of enforcement action by the CSCI. At the previous inspection a requirement was made for the home to ensure that policies and procedures covering all the topics set out in appendix 2 of the national minimum standards for younger adults are available in the home. Most of the policies detailed under appendix 2 were available but some are still outstanding. The inspector saw evidence of staff signatures to indicate that they had read the relevant policies and procedures. The registered persons must ensure that policies are available on smoking and use of alcohol, sexuality and relationships and individual planning and review. The policy on the death of a service user that required review was not available. This requirement is restated. The registered persons were required following the last two inspections to produce a financial and business plan. This was unavailable at this inspection therefore this requirement is restated for the third time. Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 X X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 3 X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 2 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 2 X X 1 1 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Downing View Score X 3 1 X Standard No 37 38 39 40 41 42 43 Score 3 X 1 1 X X 1 DS0000033029.V258676.R01.S.doc Version 5.0 Page 23 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 4, 5, 6 Requirement Timescale for action 30/11/05 2 YA6 15 3 YA6 17 Sch 3 (2) 13(4)(c) 4 YA9 The registered persons are required to review the statement of purpose and service user guide. Both documents must meet the requirements set out in regulations 4 and 5 and schedule 1 of the Care Homes Regulations 2001 and the national minimum standards for younger adults. [Previous timescale of 31/3/05 not met.] The registered persons must 30/11/05 ensure that care plans include goals aimed at supporting individuals to maximise their independent living skills. Care plans must be reviewed regularly and show evidence of involvement of the service user. [Previous timescales of 30/9/04 and 31/3/05 not met.] The registered persons must 13/01/06 ensure that photographs of individual service users are available on their files. This requirement is restated. The 30/11/05 registered persons must ensure that risk assessments are sufficiently detailed to ensure that all aspects of the service DS0000033029.V258676.R01.S.doc Version 5.0 Downing View Page 24 5 YA12 16(2)(m) 6 YA17 16(2)(i) 7 YA20 13(2) 8 YA20 13(2) 9 YA20 13(2) 10 YA27 13(4)(c) 11 YA31 19 Sch 4 (6) (e)(f) 12 YA34 19 Sch 2, 4 user’s needs are covered. Risk assessments must be reviewed regularly. [Previous timescales of 30/9/04 and 31/3/05 not met.] The registered persons must ensure that service users are involved in the planning of activities at the home and that their wishes and decisions are recorded. The registered persons must ensure the availability of food ingredients on the home so as to meet the dietary needs of service users. The registered persons must ensure that medication belonging to service users who are no longer living at the home is disposed of. The registered persons must ensure that all staff working in the home receive accredited medication training. The medication policy must be reviewed to reflect the need for accredited training for all members of staff. [Previous timescales of 31/8/04 and 31/3/05 not met.] The registered persons must provide appropriate hand washing facilities in the bathroom. [Previous timescale of 18/2/05 not met] The registered persons must ensure that job descriptions are available for the respite manager and the co-ordinator. [Previous timescales of 31/8/04 and 31/3/05 not met.] The registered persons must ensure that information detailed under schedule 2 and 4 of the Care Home Regulations is available for inspection at all DS0000033029.V258676.R01.S.doc 13/12/05 13/12/05 13/01/06 13/01/06 30/11/05 30/11/05 30/11/05 30/11/05 Downing View Version 5.0 Page 25 13 YA35 14 YA35 15 YA39 16 YA39 17 YA40 times. [Previous timescale of 31/3/05 not met.] 18(1)(c)(i) The registered persons must ensure that staff induction training is LDAF [learning disability award framework] accredited to provide underpinning knowledge for progress towards achieving national vocational qualifications [NVQs]. [Previous timescale of 31/3/05 not met.] 18(1)(c)(i) The registered persons must ensure that all members of staff have an up to date training and development plan. This must include details of NVQ training so as to ensure that the home meets the target of 50 of staff with NVQs by the end of 2005. [Previous timescales of 31/8/04 and 31/3/05 not met.] 24(2) The registered persons are required to compile a report of the findings of the quality assurance exercise. A copy of this report must be sent to the CSCI. 26 The responsible individual must carry out monthly unannounced visits to the home and prepare a report of findings. Copies of the report must be sent to the CSCI and kept in the home. [Previous timescale of 31/3/05 not met.] 17 The registered persons must ensure that the homes written policies and procedures are cover all the topics set out in appendix 2 of the national minimum standards for younger adults. Policies must include those relating to death of a service DS0000033029.V258676.R01.S.doc 30/11/05 30/11/05 13/01/06 30/11/05 30/11/05 Downing View Version 5.0 Page 26 18 YA43 25 user, smoking and alcohol, sexuality and relationships and indivdual planning and review. [Previous timescales of 31/8/04 and 31/3/05.] The registered persons must produce a business and fianancial plan that is reviewed annually and is avaialble for inspection by the CSCI. [Previous timescales of 30/9/04 and 31/3/05 not met.] 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Downing View DS0000033029.V258676.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!