Inspection on 24/11/06 for Follybridge House

This inspection was carried out on 24th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Follybridge House 18/04/08

Follybridge House 18/04/07

Follybridge House 07/02/06

Follybridge House 06/10/05

Follybridge House 28/02/05

Follybridge House 29/06/04

Follybridge House 24/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Follybridge House Bulbourne Road Tring Herts HP23 5UG Lead Inspector Gill Gentles Unannounced Inspection 22 and 24 November 2006 10:00 nd th Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Follybridge House Address Bulbourne Road Tring Herts HP23 5UG 01442 828285 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) Turning Point Limited Mr Alan Bruce Wilson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 6 residents with a learning disability and mental illness Date of last inspection 7th February 2006 Brief Description of the Service: Follybridge House is situated in a quiet rural area, backing on to a nature reserve accessible to Service Users. The home has large, attractive and wellmaintained grounds, which contain a sensory garden, a trampoline, and swings. The home is part of the charitable organisation Turning Point, which provides residential accommodation for people with learning disabilities and mental health problems. Follybridge House accommodates up to six male Service Users with behavioural problems and learning and communication difficulties. The current fees for this service according to the manager in the Pre-inspection questionnaire are £127.85 per week. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place on the 22 and 24th November 2006. The second days visit was because the manager was off on annual leave and the deputy was engaged on the first day therefore staffing records were unavailable for inspection. Policies, procedures, home records and care records were examined. The home manager and staff were spoken to. Interactions between Service Users and staff were observed. All six men living in this home are non-verbal therefore it was difficult to communicate directly. One service user spent a considerable amount of time during the inspection transfixed with the process by sitting close by at all times. The care of two Service Users was case tracked and care practices were observed. Documentation pertinent to the health and welfare of Service Users and health and safety around the home were viewed. A tour of the environment pertinent to the two service users being case tracked was carried out; this included bedrooms, bathing and toileting facilities as well as the communal areas. The commission received comment cards from four of the Service Users families, two from health care professional and one from a placing officer. Families commented that “I have high regard for the dedication and care which the staff of Follybridge have shown towards all the resident” and “our son has been at Follybridge from its opening. He is well cared for and appears content”. Medical professionals have commented that “never had any concerns over care given by the staff at Follybridge” and “staff are always helpful and provide excellent care”. The comments received from the Care manager indicate that there maybe a need to improve communication prior to any crisis situations arising. The evidence seen and comments received indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals. What the service does well: A robust policy and procedure is in place to certify prospective service users are thoroughly assessed to ensure the home can meet their needs. Personal care needs of the service users are identified through the Care Plans to ensure individual needs are met. Service users Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 6 Risk Assessments are in place to ensure service users are safe. Service users are supported to maintain contact with family and friends, to keep important social contacts. The home ensures that they cater for all service users specialist needs offering balanced and nutritious meals Effective complaints procedures are in place to ensure that issues raised by service users and their representatives are listened to. Service users are offered personal, physical and emotional support as and when required and records are clearly maintained. Medication is now managed well, ensuring that service users receive the medicines they require to keep them healthy and well. The home appears to be managed well by the manager giving clear leadership to the team and promoting continuity of care to service users and improving standards all round. Annual health and safety services are carried out appropriately ensuring service users are not placed at any risk. What has improved since the last inspection? What they could do better: Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 7 The range of activities is limited failing to access the community spending greater time in the home, which provides limited opportunities for stimulation. The staff team are struggling to manage a number of bahaviours being displayed and without the appropriate training and guidance in place are reluctant to risk venturing into the community of fear of possible consequences. Adult protection procedures are appropriately managed to ensure that service users are not placed at risk. However the organisation is failing to protect the service users, staff and public from situations that challenge. The environment is nicely decorated, clean and tidy creating a home, however shortfalls in fire safety issues could be a risk to service users. Staff records identify that staff have the competencies, qualities required to meet service users needs, however the shortfalls identified in training around physical intervention is placing staff and service users at risk. 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. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 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 Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 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): 2 Quality in this outcome is good: This judgement has been made using available evidence including a visit to this service. A robust policy and procedure is in place to certify prospective service users are thoroughly assessed to ensure the home can meet their needs. EVIDENCE: There have not been any new service users in to this home since 2000. Therefore it was not possible to ascertain whether service users are / would be assessed adequately. However, the organisation has policies and procedures in place for the manager that provides guidance on the process of admitting new service users. The policy and procedure includes clear guidelines in relation to ensuring prospective service users meet existing service users, staff and discuss how the service can meet specific needs. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 and 9 Quality in this outcome is good: This judgement has been made using available evidence including a visit to this service. Personal care needs of the service users are identified through the Care Plans to ensure individual needs are met. Service users Risk Assessments are in place to ensure service users are safe. EVIDENCE: Two service users care was tracked as part of the inspection visit. Due to the complex needs of individuals it was not possible to communicate verbally to ascertain service users views on their plan of care. One service user spent half the day in the office observing the inspection process he was calm throughout. Service users care plans are called person centre plans and are vey detailed. The plans were clear and concise and easy to follow with very specific information relating to each individual service user. All file contained information in relation to : - Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 11 · What level of support I require – drinking, using utensils, eating, using the kitchen, snacks, to make choices about food, domestic cleaning, laundry, toileting, personal hygiene, handling money, planning a menu, crosiing roads, communication, using the local area etc. · Favourite things · Positive rreputation – all the good points · Self help skills · Behavioural management · Dislikes · Leisure activities · How I communicate my needs · Life history from families. · Daily routine, what a perfect day would be and what a worst day would be. · Specific individual goals. Overall service users are unable to make comment about their plans and the level of involvement is limited. Due to the communication barriers and concentration levels. All plans are completed by the key-worker who observes and works closely with the individual and then discusses the outcomes in team meetings etc for other staff members comments. Limited choices are offered however, the level of disabilities of the service users in the home make this difficult. However, care plans did evidence some choice and control takes place and is supported and encouraged by the team, e.g. “he likes to take his dirty clothes to the laundry room and puts them in the basket”. “with encouragement will mop the floor” Follybridge has a selection of comprehensive Risk Assessments for all service users, they are very specific to individual’s needs and behaviours and incorporates triggers that may produce anxious aggressive outbursts. The format utilised consists of serveral sections, such as checklist for risk ratings, brief descritption of the risks identified, risk management plan and a summary of the risk management. All were found to be clear, concise and detiled identifying the risk to the service users, risks to others, present consequences, control measures, special precautions and actions. The staff spoken with were able to confirm the process in place for completing Risk Assessments. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The range of activities is limited, failing to access the community spending greater time in the home, which provides limited opportunities for stimulation. Service users are supported to maintain contact with family and friends, to keep important social contacts. The home ensures that they cater for all service users specialist needs offering balanced and nutritious meals. EVIDENCE: Due to the disabilities of the service users, opportunities are not really available for employment, however the two service users case tracked attended day centres in Hertfordshire. The service users living in this home have complex and diverse needs, as well as communication difiiculties and behavioural issues that arise from time to time. Therefore community and social inclusion is limited as staff expressed Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 13 concerns over the appropriate levels of support being availble when out of the home and the ability to manage situations if they arise. Activities are limited, the files of the two service users case tracked showed that very few or no activities had taken place or even been organised and planned, other than short trips in the mini-bus. Records submitted by the manager on his return from leave identify that a few trips out such as Meals out, visit to the Zoo and walks around Ashridge have taken place in the last few months. One service user has enrolled at Berkhampstead swimming which he will attend on a Saturday evening for an hour. Family and friends contact is supported and encouraged. Visitors are welcomed into the home, but need to be aware that unplanned visits may have an effect on some service users behaviours. Service users take little or no responsibilty for the day to day running of the home however staff do encourage individuals to develop skills around the home. The two service users whose care was tracked according to the care plans are encouraged to and enjoy polishing window sills, vacuuming own bedrooms, and take their clothes into the laundry and placing them in the basket. The homes staff prepare and cook all the meals and menus were seen for the previous and coming week. One service user case tracked needs a very special diet known as PKU ( pheylketonuria) high protein levels. The staff spoken too were able to explain about the condition and what it means and the need for this individual to continue on this diet. The staff have worked hard to ensure this special meal looks like everybody elses to avoid conflict. A special menu is in place for this gentleman which seems to work well. The home seemed to offer a well balanced nutritious diet. The fridge, freezer and cupboards were well stocked offering arrange of fresh and frozen foods. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 and 20 Quality in this outcome is good: This judgement has been made using available evidence including a visit to this service. Service users are offered personal, physical and emotional support as and when required and records are clearly maintained. Medication is now managed well, ensuring that service users receive the medicines they require to keep them healthy and well. EVIDENCE: All Care Plans of the two-service users case tracked identified their personal support needs and specific action for the staff team to ensure service users needs are being met. Service users are supported to access medical professionals through either the GP or the Community Learning Disability Team. A record of health care appointments, are maintained for those service users who have attended routine doctors, dental, optical appointments with a brief descriptions of the outcome. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 15 Medication policies and procedures are in place and accessible by all staff. Clear guidelines for each service user are in place for administering all medication including PRN medicines. However, it was noted that guidelines for one service users PRN was missing, this was discussed with the senior on duty. Medication is stored in a lockable cabinet on the wall. in the office. Medication for the two-service users case tracked was found to be stored adequately with appropriate documentation being in place. Medication is ordered by a delegated member of staff, who was able to explain the system for ordering and returning medication. Boots the chemist delivers all medication in a sealed bag and audits the home’s storage and recording systems on a quarterly basis. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome is poor.: This judgement has been made using available evidence including a visit to this service. Effective complaints procedures are in place to ensure that issues raised by service users and their representatives are listened to. Adult protection procedures are appropriately managed to ensure that service users are not placed at risk. However the organisation is failing to protect the service users, staff and public from situations that challenge. EVIDENCE: There is a robust complaints policy and procedure in place. The agency has received no complaints since the previous inspection. There has been no information concerning complaints received from service users or their representatives by the Commission for Social Care Inspection regarding this service Turning Point has clear policies and procedures for dealing with any incidents of suspected abuse. Five out of eleven staff have attended training in the Protection of Vulnerable Adults and three are booked on a course on the 30th November 2006. However, the home has an on going vulnerable adult issue with a staff member on suspension, which Hertfordshire Local Authority are investigating. During the inspection visit an incident was observed where a member of staff man-handled a service user in an inappropriate way. This was discussed with the deputy manager and left for him to manage. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 17 The staff had serious concerns relating to the need to use appropriate restraint techniques on service users. Turning Point do not have a physical intervention policy or appropriate training available for the staff team to handle challenging situations that may arise in or external to the home. The organisation is failing to protect its service users, staff and public by not permitting appropriate restraint techniques to be utilised for everybodys safety, therefore failing to meet individuals needs by being reluctant to interact in the community without support. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 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 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The environment is nicely decorated, clean and tidy creating a home, however shortfalls in fire safety issues could be a risk to service users. EVIDENCE: The home is situated in a rural part of Tring some distance from local shops and the town centre. The home is registered for six people, being accommodated on two floors. The home has a lovely large garden to the rear of the property backing onto a nature reserve. The bedrooms of the two service users who were cased tracked were viewed. In general they were found to be homely personalised of a domestic nature with natural and electric lighting and heating. The communal rooms were found to be clean and basic; as service users have a tendancy to destroy ornaments and pictures. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 19 The home has one bathroom on the first floor and a shower room on the ground floor which has been decorated and refurbished. However, the floor has been poorly laid and is badly stained and in need of replacing. the kitchen has been replaced and a new oven has been installed as per the required issued from the previous inspection. Appropriate infection control systems are in place and staff have received training. There were no odours detected in the home. The home has a separate laundry facility which adequately meets the homes needs. Throughout the tour and the two days of the inspection it was very evident that both staff and service users are wedging open fire doors around the property. It is required that the manager contact the local fire officer and ask for advise and guidance. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 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 34 35 Quality in this outcome is adequate: This judgement has been made using available evidence including a visit to this service. The home’s recruitment policy and practices support and protect service users from potential harm. Staff records identify that staff have the competencies, qualities required to meet service users needs, however the shortfalls identified in training around physical intervention is placing staff and service users at risk. EVIDENCE: Personal records were viewed for new staff (permanent and bank) working in the home . All files contained the appropriate information required to ensure service users are protected from harm. 20 of staff are qualified to NVQ level 2 and 20 are in the process of completing it. The mandatory training of the permanent staff is high, out of eleven permanent staff there are:· Food Hygiene - 9 · Fire Awareness - 9 Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 21 · · · First Aid - 10 Manual Handling - 7 Infection Control – 9 The staff are all booked on courses by Unique training, a company Turning Point use, and who seem to be responsible for ensuring training is up to date. Other training is promoted and encouraged, these include challenging behaviour, Person Centre Planning, epilepsy awareness etc. Apart from restraint techniques and physical intervention training which is poor. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 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): Quality in this outcome is Good: This judgement has been made using available evidence including a visit to this service The home appears to be managed well by the manager giving clear leadership to the team and promoting continuity of care to service users and improving standards all round. Health and safety procedures are carried out appropriately ensuring service users are not placed at any risk. EVIDENCE: The manager has overall responsibility for ensuring the day-to-day running of the home, managing budgets etc. He is responsible for ensuring the aims and objectives of the home are maintained in line with the Statement of Purpose of the home. He is in the process of completing the Registered Managers Award NVQ level 4. At the time of the inspection visit the manager was an annual leave. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 23 Evdiently by talking to the staff team the manager operates and open and transparent home. All staff spoken with had a clear unsderstanding of how the home operates and communication between each other was observed as being of a high standard. The deputy manager was able to locate essential staff records during the second days visit and confirmed that he and the manager were the only two people who had access to the files. The home has not had a quality audit completed this year. Turning Point have or are about to introduce a new auditing system which will be carried out in the coming months. Regular proprietors unannounced visits take place monthly and records were available for perusal. A selection of health and safety certificates was perused, such as fire, gas and portable appliances and found to be in date and regularly checked. Risk Assessments were found to be in place for individual service users and generically to the home and reviewed regularly. Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 1 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 3 3 X 3 X X 3 x Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 YA24 YA42 Regulation 23(4) Requirement Its required that the manager contacts the fire authority for advice and guidance relating to the fire doors being propped open with a variety of objects. The organisation is required to ensure that they have a physical intervention policy in place to protect service users, staff and the public from harm. The manager is required to ensure that all staff receive appropriate physical intervention / restraint techniques training. Timescale for action 01/01/07 2 YA40 YA42 Appendix 2 01/02/07 3 YA35 18(1) 01/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Follybridge House DS0000022972.V297777.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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