Inspection on 27/06/05 for FCH - 39 & 41 Derwent Road

This inspection was carried out on 27th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

Other inspections for this house

FCH - 39 & 41 Derwent Road 30/10/07

FCH - 39 & 41 Derwent Road 26/04/06

FCH - 39 & 41 Derwent Road 11/10/05

FCH - 39 & 41 Derwent Road 01/10/04

FCH - 39 & 41 Derwent Road 05/05/04

FCH - 39 & 41 Derwent Road 30/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Fch - 39 & 41 Derwent Road 39 & 41 Derwent Road Bedworth Warwickshire CV12 8RT Lead Inspector Sheila Briddick Unannounced 27 June 2005 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 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 Stationary 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. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Fch - 39 & 41 Derwent Road Address 39 & 41 Derwent Road Bedworth Warwickshire CV12 8RT 02476 314504 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) FCH - Housing & Care Mrs Claire-Louise Groom Care home 6 Category(ies) of Learning Disability (6) registration, with number of places Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Claire-Louise Groom must achieve the Registered Managers Award Level 4 by 30 September 2005. 2. Claire-Louise Groom must have the opportunity to manage a New Admission Referral to a Care Home by March 2006. Date of last inspection 1 October 2004 Brief Description of the Service: 39 and 41 Derwent Road is a registered care home for six adults with a learning disability. FCH Housing and Care, (FCH), provides personal support on a 24 hour basis for the people living in the home. The service is located in Bedworth, and is within walking distance of the small town. It is situated in a quiet lay by, with its own parking area. It has been designed and adapted for people with profound physical disabilities. The two bungalows, 39 and 41, are each home to three people, staff are employed to work across the service. Service users each have their own bedroom. Shared space consists of a bathroom, toilet, a lounge and kitchen. There is a dining area in the kitchen at number 41, and in the lounge at number 39. Each bungalow has a separate laundry room. The link between the two bungalows houses the office/sleeping room for staff. There are well presented gardens to the rear of each property, which can be accessed by service users from the lounge. There is wheelchair access to the garden areas. Parking is available at the front of the property. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two visits, one of which was to meet service users not at home at the time of the first visit. A tour of the premises took place and staff and care records were inspected. Service users and staff were spoken with at both visits and their views are included in this report. What the service does well: What has improved since the last inspection? What they could do better: At the time of the inspection serious concerns were identified concerning the condition of the boundary wall between the home premises and the property next door. Immediate action was identified as being necessary and steps were taken at the time of the inspection visit to begin the process of making the area safe. Amendment is still necessary to the statement of purpose and service user guide for the home so that prospective service users have appropriate information about the services provided and that this is available in a format to meet their communication needs. Although the recent decoration and furnishings have improved the environment further consideration needs to be taken regarding the suitability of flooring and furniture coverings meeting service user’s needs. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 Page 6 Some items of furniture and fittings require repair, to be replaced or removed if no longer in use. Staff working in the home should work more closely with specialist services when identifying written guidelines to meet specific needs and keep copies of all written information forwarded to specialists. The Commission for Social Care Inspection is not routinely being informed of incidents that affect the well being of the people living in the home, which is required. Systems of medicine management must be more robust to ensure the service users receive the medicines as prescribed. The home should be proactive in assessing the future training needs of staff if they are to continue to provide a service for the people living in this home as they grow older, and this should include developing awareness in dementia care, stoke and other ageing related conditions. 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. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 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 standard(s) 1, 2 and 3 Prospective service users do not have information about this home in a suitable format to meet their needs. Staff have individually and collectively the skills and experience to meet the current needs of service users. EVIDENCE: The statement of purpose and service user guide is not in a suitable format to meet the needs of people living in the home. The statement of purpose and tenancy contract is being amended by Friendship Housing and Care, (FCH) to ensure that they are applicable to the care home setting and plan to have this available by the end of September 2005. The complaints policy however is available to service users in a tape format. Staff spoken with demonstrated a good understanding of the needs of service users with strategies in place for reviewing and discussing individual changing needs. This includes accessing specialist support to assess changing needs from occupational therapists, healthcare specialists and psychologists. The staff working in this home are very aware of the communication needs of service users and the difficulty there can be in ensuring a full understanding of the reasons for the changed need. Effective communication skills were observed between service users and staff and information for service users is displayed in photograph format around the home, this includes staffing information. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 Page 9 Staff spoken with were aware of the need for developing their communication skills further and have developed good contact with speech therapist for training and support. Speech therapists are attending staff meetings. There is good care practice evidenced in this home of forward planning in meeting the needs of service users that may be necessary following dental surgery. This planning has included meeting with oral hygienists and dieticians in identifying care plan programmes that will be necessary following surgery. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 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 standard(s) 7 and 9 The people living this home are supported to make decisions with the assistance they need from a staff team who have well-developed communication skills. Risk management could be more robust to ensure that agreed protocols are supported by relevant specialists. EVIDENCE: Throughout the inspection visit staff were observed to respect service user’s rights to make decisions regarding activities for the day and whether to be alone or to join others in the home. Various communication aids are used by staff to enable decision-making processes and this includes photographs, symbols, tape formats and makaton signing. Staff spoken with and team meeting minutes evidence established relationships and support from speech and language therapists. Resident meetings are held monthly and minutes of meetings are maintained and these are in symbol format. Care plans seen show that the home is working closely with psychologists in identifying the changing needs of service users. This involves ensuring that service users meet regularly with specialist services in developing care plan programmes to meet needs. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 Page 11 Staff are complying with specialist service requirements of recording service user activities that have the potential to cause harm and provide this as requested for review meetings with psychology services. A copy of the monitoring charts are not held on the individuals care plan once they have been forwarded to the psychologist. Individual risk management strategies have been put in place to minimise any identified risk or hazard to service user activities. However, these protocols do not include written guidelines for staff to follow that have been agreed with specialist services. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 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 standard(s) 12 and 17 People living in this home are supported to live ordinary and meaningful lives and participate in and contribute to the communities where they are living. The dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service user tastes and choices EVIDENCE: During this inspection service users were observed to enjoy a variety of activities both in the house and the community. This included attending local Luncheon Clubs, shopping, going bowling and baking. Service users indicated their satisfaction with these activities. House meeting records show that service users have opportunity to discuss activities in the home, the local community and holidays away from the home. Staff spoken with demonstrated an understanding of the importance of individuals being enabled to participate in activities of their choice with the appropriate support. Some service users have use of their own car for accessing the community. However local taxi services are also used and local services are within easy walking distance. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 Page 13 Service users are involved in meal planning and food preparation as far as possible and recent improvements to the kitchens included provision of low working surfaces, and this has further enabled service user involvement. Staff spoken with discussed the various and individual activities in the home, which further demonstrated how service user preference is promoted in this home. Care plans evidence that the nutritional needs of service users are assessed and regularly reviewed, including risk factors associated with eating and drinking disorders by specialist therapists which includes speech and language services. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 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 standard(s) 18 and 20 The people living in this home have the necessary aids, adaptations and equipment they need to promote and maintain their independence. Staff have a thorough understanding of the clinical needs of service users and the home is eager to improve their current systems for medicine management. EVIDENCE: Occupational therapy support and advice has been sought during assessment of need for mobility equipment in the home that promotes and maintains independence for individuals. Staff have appropriate equipment for moving and handling service users and all bathrooms have been adapted to meet specific individual needs, this includes hoisting equipment, bathing equipment and support bars. All mobility equipment used by service users has been purchased by the home. Service users met during the inspection showed satisfaction with the equipment that is now provided in the home. Staff spoken with had accessed appropriate training to enable them to administer medication safely. Staff are shadowed during their induction period by a manager as part of the training and assessment of competency in medication administration. There is currently no provision for auditing staff competency as part of ongoing supervision. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 Page 15 There are written protocols for staff to follow when administering when required (PRN) medicines however, protocols examined had insufficient information to ensure that the medicine would be administered safely. The documentation used for recording the administration of PRN medicine does not include the reasons for the medicine being administered, how much was administered or at what time the medicine was given. Absence of this information has the potential to cause harm to service users. Specialist nurses have been involved in the care planning process for service users requiring insulin and this includes assessing the staff competency in insulin care. A protocol for management of epilepsy on care plans indicated that this had not been reviewed since 2001. Psychology services are involved in reviewing this protocol through day services, a copy of the reviews are not held on the care home file. Medicine is being stored appropriately and safely in the home and any excess medication is returned on a monthly basis to the pharmacy. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 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 standard(s) 23 Systems for the recording of incidents that affect the well-being of the people living in this home must be more robust to ensure that records required by regulation for the protection of service users are completed. EVIDENCE: Care plans seen show that appropriate support and guidance is being sought from psychology services in the management of behaviours that challenge. Staff spoken with had been completing necessary monitoring charts requested by psychology services which would then be reviewed as part of planning care plan programmes necessary to support specific needs. The monitoring charts were currently with psychology services and not available on the care plan. Written guidelines were in place on a temporary basis for the management of specific needs, this however had not been endorsed by specialist consultants. Incidents that affected the well-being of people in the home had not been reported to the Commission for Social Care Inspection. Staff spoken with had accessed training in the Protection of Vulnerable Adults and demonstrated an understanding of their role and responsibility in protecting the people living in the home from harm. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 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 standard(s) 24, 26, 27, 28, and 30. Recent investment has significantly improved the appearance of this home creating a comfortable and welcoming environment for those living there and visiting. Structural damage to a boundary wall has the potential to cause harm to people living and working in the home. EVIDENCE: There has been an extensive programme of refurbishment and redecoration to shared areas, bathrooms, bedrooms and kitchens. This has included provision of new carpets, purchase of furniture and fittings in shared areas and for some service users in their bedrooms, and refitting of the kitchen at 41 Derwent Rd. Service users expressed satisfaction and pleasure with the new facilities in their home. Bathroom facilities have been refurbished and refitted to provide a welcoming and safe place for personal care provision. The support and advice of occupational therapy services has been sought when refurbishing the bathroom facilities. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 Page 18 New flooring in shared areas, although bright and cheerful is not appropriate to the needs of the people living in the home. A cleaning schedule was in place for regular cleaning of the flooring, however, staining was already evident, on the new carpeting. The gas fire in the lounge at 41 Derwent Road is no longer used and the surrounding to the fire is in a poor state of repair. A drawer on the sideboard in the lounge requires repairing. The boundary wall between 41 Derwent Road and the adjacent property had structural cracks in several places from the top of the wall to the ground and appeared unstable. An immediate requirement was made on the first day of this inspection for a structural survey to be completed of the boundary wall. This had been completed on the second day of the inspection with the outcome of the survey confirming serious structural damage. The proximity of the wall to the building and access to the side of the building and back garden area posed a potential risk of harm to service users, staff and damage to property. There are effective policies and procedures in place for managing the control of infection in the home and this now includes a procedure for the cleaning of laundry sinks after washing soiled articles. The washing machines do not have sluicing facilities. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 35 The people living in this home on protected by the homes recruitment policy and practice and supported by appropriately trained staff. EVIDENCE: There is documentation in the home to show that new staff are confirmed in post only following completion of satisfactory police checks, criminal record bureau clearance, (CRB) and POVA checks. Following recruitment new staff complete an induction process that includes shadowing experienced staff, training in the administration of medicine and supervision with the registered manager. A written record of the induction is maintained. Staff spoken with made positive comments about their induction process and were working towards completing the Learning Disability Award Framework, (LDAF) Award. Staff spoken with had accessed training in communication and challenging behaviour and will be completing NVQs at Level 2 and 3. Staff confirmed that specialist services advice is sought in the care planning process and in developing skills to meet specialist needs. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 Page 20 This included Diabetic Nurses, Speech and Language Therapists, Dieticians and Learning Disability Nurses. Staff spoken with demonstrated an understanding of the needs of service users as they grow older and the necessity for the staff team to develop skills to meet these needs, and that this included dementia care and stroke awareness. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Access to the side entrance of 41 Derwent Rd is unsafe having the potential to cause harm to people accessing the building from this point. EVIDENCE: As previously identified in this report the boundary wall to the side of 41 Derwent Rd is in an unstable condition. The registered manager had reported this to FCH Housing & Care and action had begun to take place for a survey of the wall to be completed. The side entrance to this house is alongside the unstable wall and staff have to use the pathway to access refuse bins and the garden area. This activity has the potential to cause harm whilst the wall remains in an unstable condition. Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 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 2 3 x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 3 3 2 x 3 Standard No 11 12 13 14 15 16 17 x 3 x x x x 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fch - 39 & 41 Derwent Road Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 1 x E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 Page 23 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 1 Regulation 4 Requirement The statement of purpose and service user guide must be made available in a format suitable for service user needs. (Previous timescale of April 1, 2005 not met) The registered manager must ensure that staff have written guidelines to follow that have been endorsed by psychology services were meeting specific and challenging needs of service users. Records of all service user activities must be maintained on their care plan and this must include monitoring charts requested to be completed by specialist services. The registered manager must develop an auditing system for ensuring that staff maintain the necessary competencies for the safe administration of medicine to service users. A record must be maintained in the home of all medicine administered as required, containing the necessary information to evidence what was administered, the time it E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Timescale for action September 30, 2005 2. 9 13 August 30, 2005 3. 9 17 August 30, 2005 4. 20 18 September 30, 2005 5. 20 13 August 30, 2005 Fch - 39 & 41 Derwent Road Version 1.40 Page 24 6. 20 13 7. 23 17 (Schedule 3) 8. 24 23 9. 24 23 10. 24 23 11. 24 23 12. 28 23 13. 28 23 was administered, the quantity and by whom. The registered manager must ensure that up-to-date information is available on care plans regarding the current medication needs of service users and this must include upto-date protocols for management of epilepsy. The registered manager must ensure that a record is made of any incident that affects the well-being of the people living in the home and is reported to the Commission for Social Care Inspection. The registered manager must make arrangements for a structural survey of the boundary wall between 41 Derwent Rd and the adjacent property. The registered manager must make arrangements to restrict access along the pathway between 41 Derwent Road and the adjacent property except in the event of emergency evacuation of the home. The register provider must make arrangements for the temporary propping of the wall between 41 Derwent Rd and the adjacent property. The registered provider must forward an action plan for the repair of the wall between 41 to one road and the adjacent property, (to include timescales), to the Commission for Social Care Inspection. The registered manager must make arrangement for the sideboard drawers in the lounge at 41 Derwent Rd to be repaired. The registered manager must make arrangements for repair to August 30, 2005 July 30, 2005 July 5, 2005. (Met) June 26, 2005. (Met) July 12, 2005 July 19, 2005 August 15, 2005 August 30, 2005 Page 25 Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 fireplace surround at 41 Derwent Rd. 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. 4. Refer to Standard 23 28 28 35 Good Practice Recommendations It is recommended that a copy of all monitoring charts completed for psychology services is maintained on the care plan. It is recommended that the gas fire at 41 Derwent Road is removed if it is no longer in use. It is recommended that flooring in the home is replaced with the quality and design that is suitable for the needs of the service users. It is recommended that the register manager review staff training needs in dementia care, stroke awareness and other associated conditions related to the ageing process and implement any training needs identified. It is recommended that the register provider consider the purchase of a washing machine with a sluicing facility. 5. 6. 42 Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Fch - 39 & 41 Derwent Road E53 S4327 Fch 39 & 41 Derwent Road V235825 270605 Stage 4.doc Version 1.40 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!