Inspection on 21/09/05 for Ferrers Drive (3)

This inspection was carried out on 21st September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ferrers Drive (3) 19/12/07

Ferrers Drive (3) 23/10/06

Ferrers Drive (3) 18/01/06

Ferrers Drive (3) 28/02/05

Ferrers Drive (3) 21/09/04

Ferrers Drive (3) 11/02/04

Ferrers Drive (3) 17/11/03

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Ferrers Drive (3) 3 Ferrers Drive Grange Park Swindon Wiltshire SN5 6HJ Lead Inspector Bernard McDonald Unannounced 21 September 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. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ferrers Drive (3) Address 3 Ferrers Drive Grange Park Swindon Wiltshire SN5 6HJ 01793 875898 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) Ian Charles Miss Michelle Stephen Care home 5 Category(ies) of LD Learning disability - 5 registration, with number of places Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28 February 2005 Brief Description of the Service: 3 Ferrers Drive is a modern two-storey house with a large garden. The homes philosophy states that the aim is to “…provide a warm homely atmosphere which is beneficial to our residents. Independence, freedom of choice will be encouraged while offering support without intrusion. We are committed to encouraging service users to reach their full potential wishes and dreams and to strive for as much independence as possible.”This service offers care and accommodation to both men and women who have a learning disability. The service replicates principles of ordinary living and strives to provide services that take account of ‘social role valorisation’ principles. Each service user has their own bedroom and share communal areas. The service is designed for people that can manage stairs and want to live with others. Any behaviour’s must be manageable within a small domestic environment. The home, which is located in the Grange Park area of Swindon, is a partnership that trades as Ian Charles. They have one other similar care home nearby. The home has a fulltime manager and a small staff team. Typically there are two members of staff on duty throughout the day. At night time the staff take in turns to sleep at the home and to be available to assist with any night time needs or emergencies as they arise. Service users are expected to engage in day activities during the week. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out over six and a half hours. The inspector met with all service users both individually and in small groups to obtain their views on the service they receive. The inspector viewed all areas of the home and met with two support staff. The inspector found there were two requirements outstanding from the previous inspection report. The registered manager was available to assist with the morning of the inspection programme. What the service does well: What has improved since the last inspection? A significant improvement at the home is the provision of additional staff hours which now means two members of staff are on duty for a minimum of twelve hours a day. The increase in staffing levels should improve the opportunities being provided for service users The manager has made a credible attempt to develop a policy on service users holidays. Though further work is required it does show some commitment on the part of the manager to address the requirement. The policy does need to Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 6 be completed as soon as possible as service users told the inspector that they wanted to go away on holiday next year. 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. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 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 Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 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, 4, 5. Service users are provided with information about the home but are not being fully informed about the conditions of their residency. The introduction and placement of service users to the home is being well managed. EVIDENCE: The inspector examined the homes statement of purpose and service user guide and found the documents covered most points required of the standard. The service users guide has been developed using photographs of the home to enable service users to more fully understand the contents. Discussion with the manager confirmed she had also gone through the guide with service users, a practice which was later confirmed by two service users. The guide did contain a copy a copy of the service contract between the purchasing authority and the care providers but did not include the terms and conditions of residency between the home and service users which means service users have not been made aware of the terms of their stay at the home. It was a requirement at the last inspection that this information should be provided to service users. The manager reported that work is progressing to finish this document. It is a requirement that this must now be completed within the revised timescale. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 9 Since the last inspection one service user has been admitted. Examination of records demonstrated the home did receive a full assessment of need covering previous lifestyle, health and personal care needs. Records show that the service user was supported during the transition to the home by their relatives and independent advocate. Discussion with the service user confirmed they had opportunity to visit the home and meet with other people living at the home prior to admission. The inspector also spoke with two service users who stated they had met the service user during their introduction to the home. The service user has been offered a trial placement and the first month review was being held on the day of the inspection. Discussion with the service users confirmed they liked living at the home and wanted to stay. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 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) 6, 7, 9. Service users care plans reflect their needs and demonstrate how they are supported to take responsible risk. The home does enable service users to make basic choices and decisions about their lives but is failing to embrace the need to ensure they are provided with choices that are age appropriate, that promote independence, and increase community presence. EVIDENCE: The inspector looked at the care plans of four service users. The home has adopted a person centred planning approach to meet the care needs of service users. The care plans cover health and personal care needs with clear goals and outcomes recorded. There is evidence to demonstrate service users care needs are being kept under review, which also ensures the home can continue to safely meet their needs. Discussion with service users confirmed they had been involved in developing their care plan and their attendance at review meetings was recorded. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 11 Discussion with one member of staff demonstrated an awareness of the care needs of service users. Staff confirmed there is a key worker system in operation at the home though, in reality the low number of staff employed at the home and low number of service users means the effectiveness of the key worker system could not be fully evidenced. Discussion with three service users confirmed they are offered choices by staff including what to wear, what to eat and when to go to bed and get up. This is however one area that could be further developed to provide service users with more opportunity for choice in relation to community activities and social interaction. Service users stated they would like to go out for meals more and have the opportunity to have a choice of a take away meal on occasional evenings. A choice that is currently not on offer at the home. The home has shown some initiative in developing opportunity plans for service users. Although a good step towards increasing choice and community participation further thought should be given to more age appropriate activities other than puzzle books, singing, board games and segregated activities in day care settings. Individual risk assessments have been developed and reviewed in the past twelve months. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 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, 13, 14, 16. The home is supporting service users to take responsibilities for household task but needs to improve the opportunities for service users to take part in age appropriate non-segregated activities. EVIDENCE: Discussion with service users and examination of records showed that service users are supported to take part in day care services. One service user who recently moved to the home has continued with daytime activities they were engaged in prior to their move the home. The service user did confirm they enjoyed going to the centre and wanted to continue. Not all service users have a programme of activities that covers all five days, relying instead on staff to provide activities. Discussion in the previous standards has indicated there is scope to improve opportunities to ensure they are more age appropriate and promote service users community presence. Service users did confirm they had been away for day trips over the summer and that they wanted to go away on holiday next year. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 13 In response to a requirement made at the last inspection the manager has developed a policy on the provision of holidays away from the home. This document needs to be further expanded to include who is responsible for the cost of the holiday, who chooses the holiday, what staff cover would be required and who is responsible to risk assess the chosen holiday and any activities undertaken by service users. The home has made some progress in increasing the staffing levels and a new member of staff has recently commenced work. It is the inspector’s view that this appointment should improve the supervision and support provided to service users and increase opportunities and their community presence. Staff were observed to be very much at ease with service users and had a good rapport and two service users said the staff were “good”. Service users did have responsibility for small household task and this is clearly recorded in the activities/job sheet. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 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, 19, 20. Service users personal and health care needs are being met at the home. EVIDENCE: Service users care plans provide details on how they wish to be supported. Service users can also communicate their wishes to staff on what support they require. Service users health care needs are recorded as part of the care planning process. One service user stated staff help them to go the doctors. There is evidence to confirm service users are supported to attend health care appointments such as the dentist, optician and the chiropodist and a record of health care appointments are being kept at the home. Specialist health care appointments such as psychiatric services are actioned on behalf of service users. Service users current health issues are clearly recorded including any known allergies and discreet monitoring of service users weight. There is a clear record of service users current medication and their side effects. One member of staff confirmed receipt of in house medication training. No service users have been assessed as being able to safely administer their medication. Examination of records showed that the home was accurately recording medication administered and received at the home and all medication is held secure in the home. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 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 standard(s) 22, 23. Service users appear to be satisfied with the care they receive and are aware who to report any concerns to. The home needs to improve the way it records service users money and ensure staff understand their role in protecting and ensuring the safety of service users. EVIDENCE: The manager confirmed the home has received no complaints since the last inspection. The complaints procedure was on display at the entrance of the home and included the name and address of the Commissions office at Chippenham. The inspector discussed with service users who they would tell if they were not happy. Two service users stated “they were happy” and one service user did confirm they would tell the manager. Discussion with one member of staff confirmed an awareness of what to do if they had concerns regarding the welfare of service users at the home. The staff member stated they had not yet received any abuse awareness training and clearly felt they would benefit from this training. It is recommended that this be provided to all staff at the home. The inspector found the home did have policies and procedure on the protection of vulnerable adults including definitions on what constitutes abuse. The home was holding money on behalf of service users and the inspector found that although the home was keeping records and receipts of all money being held, the records were somewhat confusing. The inspector checked all five records and while the money did balance with the total, two records did have an entry relating to savings, which did not Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 16 appear to relate to the money being held. It is recommended that the home reviews this system and ensure that clear records are kept on all money held on behalf of service users. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 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, 25, 26, 27, 28, 29, 30. While the home does provides service users with a comfortable and clean environment suited to their needs, it is failing to keep on top of minor repairs and decorations to ensure the standard of accommodation does not fall. EVIDENCE: The home is located in a quiet residential area with easy transport links to Swindon town centre. Accommodation is provided on two floors with two service users bedrooms on the ground floor and three bedrooms on the first floor. All service users have a single bedroom one of which has en suite facilities. In addition there is a staff sleeping in room that also doubles as the office. The inspector viewed all areas of the home and found the overall standard of accommodation is satisfactory though parts of the home are beginning to show signs of wear and would benefit from being redecorated. It was recommended at the last inspection that the responsible person budget for these improvements for the financial year 2005/2006. The manager advised that Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 18 plans are in place to carry out these repairs and one service users bedroom had recently been decorated. Particular attention now needs to be given to repairing or replacing the bathroom panel, which had come away from the bath and repairing or replacing the wall paper in the lounge and in one service users bedroom. Discussion with service users confirmed they were more than happy with their accommodation. One service user stated they had “everything they needed”. There is adequate communal living space, which comprises of a large lounge with patio doors to the enclosed rear garden. There is a small domestic style kitchen and a separate dining room to the side. Radiators are not guarded and risk assessments have been completed to indicate they are not required for the current service user group. Toilets and bathrooms are situated close to service users living areas and have been fitted with suitable locks, which allow access to staff in the event of an emergency. Laundry facilities are located in a separate room on the ground floor well away from any food preparation area. There is a domestic style washer and dryer and discussion with staff confirmed they were sufficient for the needs of the home. There are no aids or adaptations in place at the home to assist service users independence and the inspector was informed none are needed. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 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) 33, 34, 36. The home is failing to demonstrate safe recruitment practices are being followed. The increase in staffing hours should improve opportunities for all service users living at the home. EVIDENCE: Following a requirement made at the previous inspection the home has increased the number of staffing hours provided at the home to ensure two members of staff are on duty for a minimum of twelve hours a day. In addition one member of staff provides sleep in cover at night. While the home was waiting to appoint staff the manager stated she had been providing extra cover between the hours of 8am and 8pm. However, examination of the rota only showed one member of staff on duty covering a 24-hour shift. It is a requirement that all hours worked at the home are clearly recorded. The inspector examined two staff recruitment records. The records of one member of staff who had been working at the home for over six months contained references, proof of identity, terms and conditions of employment and a satisfactory Criminal Records Bureau (CRB) check from their previous employer. This CRB is not sufficient to demonstrate safe recruitment practices Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 20 are being followed. The manager was informed that CRB’s are no longer transferable and that the home must apply for a Protection of Vulnerable Adults (POVA) first check and new CRB clearance for the staff member within seven days of the inspection. The records of the second member of staff did not have a copy of the POVA check or a CRB check. The manager stated these were still at the registered providers office and copies had not yet been sent to the home. It is a requirement that these records are available at the home for inspection to demonstrate they are protecting service users through robust recruitment practices. Discussion with staff confirmed they are supervised in the work place and have formal supervision a minimum of six times a year. Staff meetings are also being held and a written record is kept. Discussion with one member of staff confirmed they feel supported by the team and the manager. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 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) 37, 38, 39, 42. The manager is working towards improving the service and ensuring the health and safety of service users are being promoted. EVIDENCE: The manager has been in post for nine years and has considerable experience of working with people with learning disabilities. The manager has successfully completed NVQ level 4 in care and has recently applied to complete the registered managers award. The manager confirmed that she meets regularly with the registered provider and feels supported and involved in decisions that are made about the home. A requirement was made at the last inspection that the service must develop a quality audit report. The timescale for responding to this requirement had not expired. The requirement will be brought forward to the next inspection. The home has a commitment to their equal opportunities policy, which is reflected in their recruitment practices and cultural diversity of staff employed. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 22 Health and safety requirements are being met at the home. Policies are in place and held secure in the home Examination of fire logbook demonstrated fire safety precautions are being followed. Discussion with service users confirmed they were aware of what to do in the event of a fire. COSHH risk assessments are in place and all cleaning products are being held securely in the laundry room. The gas safety certificate for the boiler was dated 15/6/05. The inspector found the home had not done any portable appliance tests and it is a requirement that these are now completed. Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x 3 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 2 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 N/A 3 Standard No 11 12 13 14 15 16 17 x 2 2 2 x 3 x Standard No 31 32 33 34 35 36 Score x x 2 1 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ferrers Drive (3) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x 2 x DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 24 NO 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 5(1)(c ) Requirement The registered person must ensure a standard form of contract or/and stated terms and conditions of residency between the provider of care and each service user must be made available and be included in the service user guide. Timescale for action 01/11/05 2. 14 12(1)(3) 3. 23 17(2) 4. 27 23(2)(b) This requirement was outstanding from the previous inspection and complience must now be achieved with the revised timescale. The registered person must 01/11/05 ensure that a policy is drawn up to cover the provision of service user holidays which must include minimum levels of staff cover, who is responsible for the cost and who is responsible to risk assess the chosen holiday and any of the activities that may be undertaken by service users. The registered person must 01/10/05 ensure a clear record is kept of all money held on behalf of service users. The registered person must 01/11/05 repair or replace the bathroom panel in the first floor bathroom. Version 1.30 Page 25 Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc 5. 33 17(2) Sch 4 6. 34 19(1)(b) 7. 34 19(1)(b) (i) 8. 39 24(1) 9. 42 13(4)(a) The registered person must ensure the duty roster accurately reflects the number of hours worked by all staff, including the manager The registered person must apply for a POVA first check and CRB clearance at enhanced level for the member of staff identified at the time of the inspection The registered person must ensure all records specified in Schedule 2 of the Care Homes Regulations 2001 are available at the home for inspection. In particular the home must demonstrate a satisfactory CRB check has been obtained for all staff prior to commencing work. A detailed quality report must be compiled as to the way the home is meeting its main objectives. Such a report should include what the home does well i.e. its strengths: and what the areas the homes needs to improve on i.e. its weaknesses. It should seek out and take into account the views of those who live at the home including their relatives and those people such as day care staff, health care workers and social workers who may be able to comment on the standard of care the home provides. The report should include key issues such as the number and the quality of the staff who work at the home, levels of comfort, meals, range of activities, safety the way personal and health care is delivered, and any other relevant concerns. A copy of the report (which can be done in modules) must be sent to the Commission by 21/10/05 The registered person must 01/10/05 28/09/05 01/10/05 21/10/05 01/12/05 Page 26 Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 ensure that portable appliance testing is carried out by a operson whio has the relevant knowledge and skills and is competant to carry out the test. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 5 7 & 13 Good Practice Recommendations The registered person should ensure service users contract confirm the room to be occupied, and confirm any extra charges and details listed under NMS 5. The registered person should consult with service users and consider how to increase opportunities to enable them to make choices and decisions about their lives that are age appropriate, promote independence and community presence. The registered person should ensure all staff receive training in abuse awareness. The registered person should ensure a budget is in place to part redecorate the inside of the home paying particualr attention to the halls, stairway and service users bedrooms. 3. 4. 23 24 Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 Page 27 Commission for Social Care Inspection Suite C, Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ferrers Drive (3) DD51_D01_S3196_3FERRERSDRIVE_V226526_210905_STAGE4.doc Version 1.30 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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