Inspection on 08/12/05 for Fox View

This inspection was carried out on 8th December 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fox View 03/11/08

Fox View 07/11/06

Fox View 12/10/04

Fox View 07/07/04

Fox View 10/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Fox View 3 Fox View Halifax Road Dewsbury West Yorkshire WF13 4AD Lead Inspector Alison McCabe Unannounced Inspection 8th December 2005 10:30 Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fox View Address 3 Fox View Halifax Road Dewsbury West Yorkshire WF13 4AD 01924 458187 01924 458187 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) St Anne`s Community Services Ms Sara Jackson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person with a physical disability and a learning disability. Date of last inspection 12th October 2004 Brief Description of the Service: 3 Fox View is a care home with nursing, registered to provide care and accommodation for six adults with learning disabilities, including one named service user who also has physical disabilities. The home is operated by a charitable organisation, St Anne’s Community Services. The property is a purpose built bungalow with a large enclosed garden to the rear and parking facilities to the front. It is located at the front of the grounds of Dewsbury District Hospital, next to living accommodation for hospital staff, a palliative day care centre and a respite care home. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by one inspector between 10.25am and 1.25pm. The inspector had discussions with the manager and staff on duty and spent time with service users who were at home. The inspector checked progress in addressing requirements and recommendations made at the previous inspection and as a result of a complaints investigation conducted by CSCI. Many have been addressed, however some remain outstanding and have therefore been brought forward as part of this inspection. The inspector sampled service user records, health and safety records and staff training records. A tour of the premises was not conducted on this occasion. The home has seen some significant changes since the last inspection, with two service users having moved out of the home and staff vacancies being filled. This has allowed for a more stable period with staff having more time available for the remaining service users. What the service does well: What has improved since the last inspection? Service users are offered opportunities to access community based facilities and activities on a regular basis. Medicine management at the home is good; overstocks of medication have been returned to the pharmacy. Vacant posts have been filled. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4,5 Good arrangements are in place for assessing service users before they move into the home. There are clear, written agreements about what service users should expect from the home and service. EVIDENCE: At the time of inspection, Fox View had two vacancies. The manager reported that a prospective new service user had been assessed and was in the process of having visits to the home. Records of visits and contacts have been kept. A Community Care Assessment has been completed in respect of this individual. The manager reported that the family of the prospective new service user had been invited to attend the Christmas party in order to meet other parents and service users. Following a recommendation made as a result of a complaints investigation completed in July 2005, the manager reported that staff have all been made aware, in staff meetings, of their responsibilities to keep families informed of incidents involving their relative, as agreed as part of their individual plan. Those service user records that were examined had an individual written contract setting out the terms and conditions of their stay. As recommended at the previous inspection, arrangements for reviewing needs and updating the service user’s plan have now been included in the licence agreement. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 9 Standard 3 was not assessed in full, however the recommendation made at the previous inspection to make clear in service user files what information is historical and what is current has been addressed and this is positive. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 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): 6,9 Some parts of service users’ care plans were clear and detailed, however some parts need to be more detailed so that staff have clear guidance about how to meet individuals’ needs. Some service users’ risk assessments need to be more detailed. EVIDENCE: Individual plans for two service users were examined as part of this inspection. Some information was clear and informative, however some information needs to be clearer. For example, more detail about the nature of assistance required with personal care is necessary, particularly for those service users who would find it difficult to communicate their needs and preferences. A person centred planning approach is used at this home which is positive. There was evidence in the records that service users and their relatives are involved in this process. It was noted that some of the goals agreed within the person centred planning meeting, and recorded in the minutes, had not been transferred to the individual plan, for example, attending hydrotherapy, having one to one time with staff. It was unclear from the records whether some agreed objectives had been met. Examples of this were discussed with the manager at the time of inspection. The manager was confident that the objectives had been met, however had not been recorded. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 11 Risk assessments relating to two service users were examined. Some gave clear guidance to staff about identified risks and actions required to minimize these risks. Some require further detail to ensure that staff are clear about how they are expected to reduce identified risks. For example, in order to stop a specified behaviour, the risk assessment instructs staff to intervene however does not make clear what the intervention should be. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 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): 12,13,14,15 Good opportunities are offered to service users to participate in leisure, educational and community based activities. Service users are offered good support to maintain contact with their family and friends. EVIDENCE: Since the last inspection, two service users have left Fox View and there are currently only four service users being accommodated. The manager reported that this has had a positive impact on the remaining service users in terms of the frequency and range of activities available both inside the home and in the community. The manager reported that service users get out of the house most days if they choose to. Records examined confirmed this. Two service users are currently on a waiting list to receive day services provided by the local authority. A service user is currently receiving three days per week at a day centre and a service user attends three sessions per week at Oxfield Court, a day service provision operated by St Anne’s. Support staff at the home have established a leisure group where they meet to discuss and plan leisure activities in line with service users’ interests and hobbies. The manager and staff reported that service users each have the opportunity to choose what Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 13 they would like for meals and are then supported by staff to do the food shopping. This is good practice. Through discussion with the manager and examination of records, there was evidence that service users are supported to maintain contact with family and friends. Staff facilitate this where necessary. For example, a service user is provided with transport and staff support to meet his friend who lives in another St Anne’s service. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 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): 18,19,20 Good support is offered to service users to have their personal care needs met, however records in this area need to improve. Records do not demonstrate that all the identified health needs of service users are addressed. Medicine management is good at this home. EVIDENCE: Staff were observed to offer personal support in a sensitive and respectful manner. As discussed previously in this report, further detail needs to be added to some individual care plans about service users’ preferences about how they are supported with their personal care. Service users appeared to be well cared for; for example it was clear that support had been given with hair styling and applying make up. Service users have a health action plan which is positive. An OK health check is conducted with service users and objectives transferred to the health action plan. Information recorded within the action plan was not always consistent with the information in the OK health check. Records examined showed that service users are supported to attend routine health check appointments, for example, dentist, optician and well man clinic. As previously mentioned, it was not always clear from the records whether health care objectives had been Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 15 achieved. For example, records stating that a further dental appointment was required in two months showed that the appointment was not attended for a further five months. The manager reported that this was because an appointment could not be given earlier, however there was no record of this. A service user’s annual “well man” check was due in June 2005 but there was no record to demonstrate that this had happened although the manager advised the inspector that she thought this had taken place. Within a service user’s health action plan, an objective was to lose weight. There was evidence to show that the service user was weighed regularly and that there had been some weight loss, however there was nothing in the records to inform staff of the service user’s ideal weight; this must be included. Medication was examined and all tallied with records kept. The manager confirmed that prescriptions are checked by nursing staff before they are given to the pharmacist to be dispensed. Satisfactory PRN protocols are in place. The overstock of medication found at the last inspection has been returned to the pharmacy and a record of this kept. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 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): 22,23 The home has a clear complaints procedure that is available to service users. The home has good procedures in place for the protection of service users, however some records and reporting in respect of accidents/incidents need to improve. EVIDENCE: A comprehensive complaints procedure is in place that is in line with the Care Homes Regulations 2001. The procedure is also available in symbol format. Since the last inspection the CSCI have investigated a complaint at the home. There were eleven elements to the complaint, six were upheld, four were not upheld and one was unresolved. A number of requirements were made as a result of the investigation and compliance with these has been assessed as part of this inspection. Any interested parties can request a copy of a report summarizing the elements of the complaint, the outcome of each element and the requirements and recommendations made as a result of the investigation. St Anne’s has investigated two separate complaints from the same complainant concerning the content and the implementation of the visitors’ policy at the home and the closing of a building society account. In response to the first complaint, an amendment was made to the policy and an apology made and the complainant and St Anne’s have agreed the following form of words should be included in CSCIs report; “A complaint was received from a family member in relation to the implementation of the visitor’s policy at Fox View. St Anne’s has responded to this complaint and acknowledges that there were some shortcomings in how this issue was dealt with. St Anne’s apologised for these shortcomings, the complainant has accepted the apologies and the Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 17 matter is now resolved.” The revised visitor’s policy was sent to the complainant. In respect of the closing of an account the following statement was agreed with the complainant and St Anne’s: “A complaint was received from a family member in relation to the handling of the closing of their relative’s building society account by the registered manager at Fox View. St Anne’s has responded to this complaint and acknowledges that there were some shortcomings in how this issue was dealt with. The complainant has accepted the apologies and the matter is now resolved” St Anne’s upheld these complaints. A requirement made following the complaints investigation conducted by CSCI concerning the timescales within which the organisation must inform any complainant of action to be taken was not assessed fully during this inspection as no further complaints have been received by the home since. A satisfactory protection procedure is in place in addition to the Kirklees’ joint agency guidelines. Staff have received training in the protection of vulnerable adults provided by Kirklees Metropolitan Council. Concerns regarding the number and monitoring of incidents of service user to service user assaults were raised at the previous inspection. Since then, two service users have moved out of the home and the number of incidents has decreased significantly. The manager explained that the service manager is responsible for monitoring any incidents recorded at the home on a monthly basis. The manager or deputy manager is responsible for signing all accident/incident forms and are therefore aware of all incidents. In the event of an incident that requires a referral to the adult protection team, the enquiry co-ordinator from St Anne’s makes the referral. The manager reported that no referrals had been made since two service users had moved out of the home. As a result of the CSCI complaints investigation referred to above, requirements were made in respect of reporting incidents/accidents to the CSCI, and the recording of injuries to service users. Through examination of accident/incident records it was noted that some accidents/incidents had not been reported as required. This was discussed with the manager at the time of inspection. It was also noted that some records of injuries to service users were not sufficiently detailed. Further information needs to be recorded about the size, colour etc of any bruises noted to ensure that effective monitoring takes place. A requirement regarding these matters has been made. A requirement made as a result of the complaints investigation concerning the development of clear behavioural management and physical intervention plans is no longer relevant for the service users who are accommodated at the home. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 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): EVIDENCE: Not assessed on this occasion. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 There are sufficient numbers of staff working at this home. Service users are supported by staff who have relevant qualifications or who are working towards achieving relevant qualifications. Relevant training is provided to staff. EVIDENCE: Staff records that were examined each contained a copy of individuals’ job descriptions. The manager reported that, through discussion in staff meetings and supervisions, staff are familiar with the aims, values, policies and procedures of the home. A recommendation made at the last inspection to seek specialist behavioural support for a service user is no longer relevant as the individual has since left the home. Since the last inspection, all staff vacancies have been filled with the exception of twenty qualified nurse hours. The manager explained that she has decided to keep these hours vacant as it allows for flexibility of working; additional staff can be brought in for specific service user related activities. The manager reported that having a full complement of staff has had a positive impact on the service users as a consistent staff team supports them. Of eight care staff, two have achieved NVQ level 3, and one is an NVQ assessor. Four care staff have achieved the Learning Disabilities Award Framework certificate, and five Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 20 are currently working towards NVQ level 3 in care. Of six registered nurses, four are NVQ assessors. The number of assessors at the home has had a positive impact on the progress of care staff in working towards their NVQ qualifications. The inspector did not fully assess standard 34, however the manager reported that the organisation is still in discussion with CSCI regarding recruitment records being held centrally. Records required under the Care Homes Regulations 2001 are not all available within the home. The requirement made at the last inspection regarding this has therefore been brought forward, and the inspector will assess this in full at the next inspection. There is a comprehensive training and development plan in place. Training that staff have received includes movement and handling, food hygiene, adult protection, health and safety, promoting positive behaviour, epilepsy. The manager said that staff were booked to receive further emergency aid training in the week after the inspection. This is in addition to NVQ training which is ongoing. New care staff complete the Learning Disability Award Framework induction and foundation training. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,41,42 Satisfactory quality assurance and monitoring systems are in place at this home although a system for publishing the results needs to be developed. Record keeping is good in some areas, however needs to improve in some other areas. The health, safety and welfare of service users is protected. EVIDENCE: Questionnaires are sent to relatives/friends of service users seeking their views about the quality of service offered. Due to the level of understanding, questionnaires are not distributed to the service users currently accommodated at the home. The manager was unsure if the results of the questionnaires were published or made available to service users or other interested parties; a requirement has been made in respect of this. The home has an annual development plan that is available in the home. The manager reported that the home has regular standard setting meetings where the quality of the service is monitored. A recommendation made at the previous inspection to ensure that relatives of service users are informed about forthcoming inspections has been addressed. The manager reported that all relatives would Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 22 be notified in writing of forthcoming inspections. A notice would also be put on the office door so that visitors are aware of the dates of inspection. As discussed previously in the report, some records required by regulation need to be developed further. Some accident/incident reports need to be more detailed and the registered person must ensure that all events that need to be notified to the CSCI are done so promptly. Records regarding health and safety matters were in good order. There was evidence in the records that the required checks and maintenance of safety and specialist equipment is carried out. Evidence that regular fire drills are carried out to ensure that service users and staff are aware of the procedure was seen in the records. Risk assessments regarding health and safety matters are up to date and available. All staff receive training in health and safety. Since the last inspection, a number of restrictions previously placed upon service users in respect of accessing all areas of their home have been lifted. Bathrooms, toilets, the dining room and kitchen were all unlocked and accessible to service users in line with their assessed needs. The manager reported that this has had a positive impact on the quality of life of service users living at the home. Fox View DS0000001084.V271179.R02.S.doc Version 5.0 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 X 3 X 3 3 Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 X X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 3 1 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fox View Score 1 1 3 X Standard No 37 38 39 40 41 42 43 Score X X 1 X 1 1 x DS0000001084.V271179.R02.S.doc Version 5.0 Page 24 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 YA6 YA18 YA41 Regulation 15(1) 12(1)(b) Requirement A current individual care plan that includes personal support plans must be in place for all service users accommodated at the home. This must be implemented as agreed or a record kept explaining any changes. Detailed risk assessments must be in place for all service users. Risk assessments currently in place must be reviewed to ensure they contain sufficient detail. The registered person must ensure that health action plans are implemented as intended and records are kept to demonstrate this. The registered person must record the details of any accident or injury to service users at the care home, including the nature of any injury. Bruises or injuries reported to, or discovered by staff must be examined and accurate records kept of the injury or bruise. Timescale for action 15/02/06 2 YA9 YA42 13(4) 15/02/06 3 YA19 YA42 12(1)a 15/02/06 4 YA23YA41YA42 17(1)(a) Sch3(3)(j) 15/01/06 Fox View DS0000001084.V271179.R02.S.doc Version 5.0 Page 25 5 YA34 6 YA34YA41 7 YA39 8 YA41YA42 Timescale of 15/8/05 unmet. 19 The registered person has documentary evidence that anyone employed by them or another person, who is working at the home, is fit to work there. Timescale of 31/12/04 unmet. 17(2) A record is kept in the home in respect of each person employed, which contains all the information stipulated in Schedule 4(6) of the Care Homes Regulations 2001. Timescale of 31/12/04 unmet. 24(2) The registered person must make the results of service user/relatives surveys, in respect of quality of care provided, available to service users. 37(1)(e)(f) The registered person must notify the CSCI, without delay, of the occurrence of any accident or event in the care home, which adversely affects the well-being or safety of any service user. This must include any incident of service users being assaulted by other service users. Timescale of 15/8/05 unmet. 15/02/06 15/02/06 07/03/06 15/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA32 Good Practice Recommendations The registered person should continue working towards 50 of all care staff achieving NVQ level 2 or above. DS0000001084.V271179.R02.S.doc Version 5.0 Page 26 Fox View Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Fox View DS0000001084.V271179.R02.S.doc Version 5.0 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. 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