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Inspection on 28/02/06 for Easemore Road, 164b

Also see our care home review for Easemore Road, 164b for more information

This inspection was carried out on 28th February 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is welcoming and relaxed, and service users and staff relate well to each other. All service users go to college, work or a day placement, and have an increasingly varied programme of leisure activities. Staff are committed and caring, and keen to further develop the service with a person centred focus. Service users individuality is recognised, and each is involved in the daily routines within the home and encouraged to take part in decision making as far as they are able to do. There is evidence that the new manager is well organised in her work, leading the development of good care practice, and establishing and maintaining sound, effective records. Good progress has been made in addressing most matters previously needing attention.

What has improved since the last inspection?

After significant staffing changes, recent recruitment has been successful and there is now a stable staff group including three relief staff, who are developing together as a team. Only one vacancy now remains to be filled. The core team now includes two male staff, which has notably benefited the all male group of service users. Staff have begun to undertake training in person centred planning and introduce this approach into personal care recording, and health action plans are being established for all service users. Staff are booked to attend courses in total communication techniques and have set up communication boards for each service user. Service users are now planning holidays, with two going to Spain with staff and one holidaying with his parents, and staff are also aiming to help them look at opportunities for weekend breaks. A new resources manager is making improvements to the accommodation and facilities. The kitchen has been refurbished and redecorated with service users choosing the colour scheme, and on the day of inspection one service user had been shopping with staff for new garden equipment including outdoor games.

What the care home could do better:

While the staff team has worked on improving the information provided to service users, with amendments to reflect the organisational changes and provide more detailed information about the service, some details still need to be corrected, and the new documents still await implementation by the organisation.The information for service users must be accurate. A statement of purpose, service users guide and terms and conditions of residence must now be in place, which fully reflect the new organisation which has had responsibility for the home since April 2005. The problems with the boiler and central heating identified at the last inspection have received attention but not yet been resolved. It is essential this is now addressed promptly, fully and satisfactorily without further delay. Staff need to be suitably trained in matters such as adult protection, the needs of service users associated with ageing, and specialist care practice relating to service users with individual needs that may challenge the service. Arrangements need to be made to ensure staff records are available for inspection if required.

CARE HOME ADULTS 18-65 Easemore Road, 164b 164 Easemore Road Redditch Worcestershire B98 8HH Lead Inspector S Davies Unannounced Inspection 28th February 2006 13:35 Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Easemore Road, 164b Address 164 Easemore Road Redditch Worcestershire B98 8HH 01527 597883 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) www.macintyrecharity.org MacIntyre Care Ms Amanda Elizabeth Lewis Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate two service users who have additional physical disabilities. 13th October 2005 Date of last inspection Brief Description of the Service: 164b, Easemore Road is registered to provide residential care for up to 4 adults who have mild to moderate learning disabilities, including 2 people who may also have an additional physical disability. The premises is a detached, purpose built property, situated in a pleasant residential area, within walking distance of Redditch town centre. The bungalow is located on the same site as a separate house for 4 people with mild learning disabilities, who have supported living arrangements. The Registered Provider is MacIntyre Care, who has recently taken over this responsibility from the Royal Mencap Society. The property is leased from the New Era Housing Association. The stated purpose of the organisation is, ‘to be recommended and respected as the best provider of services for people with learning disabilities throughout the United Kingdom.’ Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine, unannounced inspection was to follow up previous requirements and recommendations, and to look at aspects of care practice, service users daily life, staff recruitment and competence. The inspection took place in mid winter. It was cold, and snowing. The inspection lasted approximately 3 hours, and time was spent talking with the 3 staff on duty, and 3 of the 4 service users living at the home. Time was also spent with the deputy and looking at documentation. Notwithstanding the heating problems, below, everyone indicated they were happy to be living and working at 164b, Easemore Road. The central heating boiler had broken down that day, again, and with the exception of the lounge, which was heated by a gas fire, there was no heating and the rest of the house felt very cold. Suitable arrangements had been made for temporary heating and delivery was awaited in the afternoon when service users were due to return home. This was not an isolated occurrence, and has been the subject of a previous requirement. Such repeated breakdowns are not acceptable in this service, therefore it is essential effective action is taken to fully resolve the problems. The assistance and co-operation given throughout the inspection was appreciated. What the service does well: The home is welcoming and relaxed, and service users and staff relate well to each other. All service users go to college, work or a day placement, and have an increasingly varied programme of leisure activities. Staff are committed and caring, and keen to further develop the service with a person centred focus. Service users individuality is recognised, and each is Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 6 involved in the daily routines within the home and encouraged to take part in decision making as far as they are able to do. There is evidence that the new manager is well organised in her work, leading the development of good care practice, and establishing and maintaining sound, effective records. Good progress has been made in addressing most matters previously needing attention. What has improved since the last inspection? What they could do better: While the staff team has worked on improving the information provided to service users, with amendments to reflect the organisational changes and provide more detailed information about the service, some details still need to be corrected, and the new documents still await implementation by the organisation. Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 7 The information for service users must be accurate. A statement of purpose, service users guide and terms and conditions of residence must now be in place, which fully reflect the new organisation which has had responsibility for the home since April 2005. The problems with the boiler and central heating identified at the last inspection have received attention but not yet been resolved. It is essential this is now addressed promptly, fully and satisfactorily without further delay. Staff need to be suitably trained in matters such as adult protection, the needs of service users associated with ageing, and specialist care practice relating to service users with individual needs that may challenge the service. Arrangements need to be made to ensure staff records are available for inspection if required. 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. Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 8 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 Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 5 Action taken in response to previous requirements was reviewed, finding the service itself had given the matter attention but that the providers had not yet implemented the response. EVIDENCE: The statement of purpose was not available having been revised and returned to the providers’ head office for implementation. The service users guide and contract seen still contained references to the previous providers and to the National Care Standards Commission. It is understood work has been done in the home to improve the information the service users guide provides, and that this now awaits the providers’ attention from head office. It was unclear what action had been taken to amend the contract, but the example seen had been drawn up and signed by the previous providers and still contained references to them. A valid contract for the present service needs to be drawn up and agreed with each service user, with a dated copy signed by all parties to the contract on the service user plan. Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 10 Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 11 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, 8 Service user plans are being updated well to reflect a person centred planning approach. Service users are being encouraged and supported to contribute more to decisions about their home and their own lives. EVIDENCE: Following staff training, service user plans are being rewritten from a person centred point of view, and contain detailed information emphasising positive characteristics while being clear on problem areas. For example ‘how does my behaviour serve me?’ provides helpful insights for staff in understanding how the service user feels and the reasons behind certain behaviours. These records are comprehensive, articulate and are building into effective guidance for staff in understanding and meeting each service users needs in a way which suits them. Service user plans are kept under review. One example seen dated 18/07/05 was very detailed. It would be good practice to note any action planned and Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 12 identify who is responsible for carrying it out and when, and to include the date the next review is due. Updated plans should be signed and dated. Staff have been improving their communication skills and further training is planned. They have set up symbolised communication boards, to share information with service users about day to day matters so that they know more about what goes on. For example boards in their rooms show their personal activities, and a notice board shows which staff are going to be on duty. Having such information available is part of a process towards helping them be more independent. Attendance on a training programme in total communication techniques will enable staff to build effectively on this good start. Evidence from discussion, observation and in their plans, shows service users are consulted including use of a quality assurance process, and their rights to make their own decisions are upheld and supported. One to one support helps them make personal choices and decisions, and there are recorded weekly service user meetings where staff help them to understand and contribute to decisions on matters affecting their day to day lives. Recent topics have included holidays, the kitchen colour scheme, and garden equipment. Where assessed as unable to manage their own affairs, this is recorded in their service user plans with details of staff input. For example, no service users are able to manage their own finances independently. The service user’s plan seen contains the assessment and a statement of how staff help him, with clear strategies to protect him from financial abuse. Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 13 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, 17 Service users are taking part in a wider range of activities. Meals are varied according to the time and day of the week, with respect for personal preferences and a focus encouraging healthy eating EVIDENCE: Leisure opportunities have been extended to include more sporting and active interests, with visits to the gym, and equipment purchased for home use such as table tennis, pool table, and garden games equipment. More links are being sought with the local community (for example through the gym). Service users were keen to start using the garden equipment they had just been out to buy. Mealtimes are flexible to suit service users needs and activities, and are organised to reflect service users choices. Food stores contain a range of cereals and porridge for breakfast, which service users can choose from together with eggs and toast. A range of fresh ingredients is available for sandwich fillings or ready meals, which service users choose from together with fruit to take for lunch at their day activities. Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 14 During the inspection one service user was working alongside a staff member to prepare a casserole he had chosen from a book of recipes and pictures, for the evening meal. Each service user chooses and prepares the main meal once a week, and anyone can have an alternative if they prefer. Two service users on special diets are supported appropriately while the benefits of healthy eating are generally promoted. This approach to meals aims to give everyone a chance to choose what they like to eat and help prepare this meal, and while it is noted that they share similar tastes it allows for different choices on the day. It would be good practice to keep more detailed individualised food records, which might also offer opportunities to widen choices and introduce more personal variety. Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 15 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 A review of action to meet previous requirements shows health action plans being introduced, which should enhance service users’ role in their own health care and further improve health care recording and monitoring. EVIDENCE: A review of health care records showed a careful approach being taken to managing service users health care, and this was reflected in the standard of recording. The example seen provides detailed information about all aspects of the service user’s health care, appointments and medical interventions, together with follow ups and outcomes. Health action plans have recently been introduced which, together with the developing emphasis on person centred planning, should help staff improve service users’ participation and the focus on their own perspective and experience. Staff spoken to were very enthusiastic about health action plans and the way they will help give service users a more central role in their own health affairs. At the last inspection the needs of one older service user were discussed and it was agreed to seek staff awareness training on managing and supporting the processes, including special conditions such as dementia, associated with Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 16 ageing. This is still awaited. However, training in relation to the terminal illness and death of a service user is planned, and staff have now begun to raise with service users and their families their wishes about arrangements following their death. One service user has been able to state his wishes clearly and these are now recorded in his service user plan. Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 17 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): 23 Discussion showed staff are familiar with the organisation’s and local policies and procedures on adult protection. However they have received only basic training on safeguarding service users from abuse and the management of challenging behaviour, including the use of physical intervention, and this must be addressed with regard to the particular needs of the service users using this service. EVIDENCE: Staff spoken to were committed to the principles of safeguarding vulnerable adults, and familiar with local procedures on the action to be taken in the event of an allegation of abuse. However, although support and guidance had been obtained from the behavioural support team in relation to one service user, past training had not fully addressed the potential challenges arising from the needs this service seeks to meet. There is a need to develop understanding and skills specifically relating to the management of challenging behaviour, including physical intervention. Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 18 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 This was not inspected in detail, but action in response to a previous requirement was reviewed. This showed that while steps had been taken to resolve malfunctioning of the boiler these had been unsuccessful, and further action is now needed to make sure the central heating and hot water systems are functioning fully and reliably. EVIDENCE: This inspection took place on a very cold snowy day in mid winter. At the time of the inspection the boiler and therefore central heating system had broken down that morning and was not working, the only source of heat in the home being from the gas fire in the sitting room. Although this did also affect the provision of hot water, an immersion heater was providing backup. The deputy had arranged for the delivery that day of freestanding low surface temperature electric radiators for every room, and these were awaited. The deputy explained that there had been repeated problems with boiler breakdowns since the previous inspection, that the providers were aware a more comprehensive and satisfactory solution was now needed and that they intended to take suitable action. Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 19 On a separate matter, the fire service has been consulted and confirmed that they would have no difficulty with access to the property in the event of attending a fire. Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 20 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, 33, 34 Not all staffing records were available for inspection, and the deputy was unsure of her authority to release confidential records. The inspection of these standards is therefore incomplete, and they will be reviewed at a later date. Service users are supported by a new but competent staff team. Staff members have relevant experience and training, and the qualities needed to care for service users well. EVIDENCE: Staff recruitment records are kept at the organisation’s head office and were therefore not available for inspection, so it is not possible to comment on whether robust recruitment procedures are followed. Other staffing records are kept on the premises in a locked cabinet, the deputy made these available under her control but was unsure of her authority to release confidential information and sought to protect confidentiality. This is to be commended, however records do need to be available for inspection if required and arrangements must be clarified. Following major staff changes and recruitment difficulties, there are now six core and three relief staff, with a registered manager and new deputy in post and only one vacancy remaining. Two men have joined the team, which is a welcome development for the all male service user group and already Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 21 benefiting them. A more stable team is now developing which should provide the consistency and continuity of care these service users need. The information available from records, observation and discussion with staff showed a good knowledge and understanding of service users needs and an ability to relate well to them in a supportive and friendly way, with respect and a strong commitment to their best interests. The providers expect all staff to attain National Vocational Qualification level 2, and staff said they receive positive support and encouragement to achieve this. Training has been provided from a number of sources and staff have welcomed the new providers’ own training and development programme, however this is not fully in place yet, and there are gaps which do need to be addressed systematically. There is a good awareness of special needs and an understanding of the communication function of challenging behaviour following guidance from the behavioural management team regarding one service user, but staff acknowledge the value of further training to help them support service users even better. Although staff are aware of special communication techniques, their training in this area is limited and further training is awaited, while the need for more training in the management of challenging behaviour and the use of physical intervention links with the need for training on safeguarding service users from abuse, identified in standard 23. Action is needed to make sure staff receive this training. Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 22 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): 39, 43 A quality assurance system has been introduced but not yet fully implemented. Good progress is being made in service development, and in house action to meet requirements is generally timely. This needs to be matched by the organisational response to ensure all matters are dealt with promptly and effectively. EVIDENCE: Service users’ and their families’ views have been sought as part of a quality assurance system. This still awaits an audit of the results and establishment of an action plan, and a report needs to be provided to the Commission as previously required. Many changes have taken place in this service in recent months, with improvements beginning to take effect and show benefits for the service users. There is evidence of improved management and leadership, greater staffing stability, improved recording, and real progress towards a person centred approach. There is positive staff feedback about working for MacIntyre Care, Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 23 citing a shared ethos and the approachability of, good communication with and support from senior personnel. This provides a welcome basis for assuring continued good progress at service level, but more timely responses are needed where action to meet requirements is an organisational responsibility. Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 24 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 2 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X 2 X X 2 X X X 2 Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 25 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 YA1 Regulation 6 Requirement The statement of purpose and the service users guide must be revised to accurately reflect the services and facilities available (Requirement from previous inspection for action by 30/11/05 not yet met) The contract/statement of terms and conditions must be amended to reflect the organisational changes. A valid contract needs to be in place for each service user (Requirement from previous inspection for action by 30/11/05 not yet met) Service user plans must contain an assessment of service users communication needs and how these are to be addressed. Training must be provided for all staff on meeting the needs associated with ageing, death and bereavement Training must be provided for all staff on all aspects of abuse Central heating and hot water equipment must be satisfactory for its purpose and maintained in DS0000064300.V279937.R01.S.doc Timescale for action 31/05/06 2. YA5 15 31/05/06 3. YA6 15, Sch 3 30/06/06 4. YA21 18 30/06/06 5. 6. YA23 YA24 13 23 31/05/06 15/05/06 Easemore Road, 164b Version 5.1 Page 26 7. 8. YA34 YA39 17 24 good working order – specifically, the fault with the boiler/thermostats must be rectified without further delay, or the equipment replaced. (Requirement from previous inspection for action by 30/11/05 not yet met) Arrangements must be made to 30/04/06 ensure the availability of staffing records for inspection if required The quality assurance system 30/06/06 must be fully implemented at the home, and a copy of the audit submitted to the Commission 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. Refer to Standard YA6 Good Practice Recommendations Service user plans should be reviewed six-monthly, be signed and dated, and record details of staff responsible for carrying out planned actions and when this is to happen Total communication training should be provided for all staff Records of food provided should be in sufficient detail to show food actually provided for each individual each day 2. 3. YA6 YA17 Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Easemore Road, 164b DS0000064300.V279937.R01.S.doc Version 5.1 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. 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