CARE HOME ADULTS 18-65
Greenhill Lodge 22-24 Alexandra Road Watford Hertfordshire WD17 4QY Lead Inspector
Mr Neil Fernando Unannounced Inspection 5th July 2006 10:20 Greenhill Lodge DS0000019416.V302830.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 Greenhill Lodge DS0000019416.V302830.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. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Greenhill Lodge Address 22-24 Alexandra Road Watford Hertfordshire WD17 4QY 01923 241 957 01923 229 236 greenhilllodge-londoneast@muca.org.uk 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) The Mental Aftercare Association John Warner Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Physical disability (10) of places Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. This home may accommodate 10 people with a mental disorder or physical disability (when associated with mental disorder). 6th February 2006 Date of last inspection Brief Description of the Service: Greenhill Lodge is a care home offering accommodation to up to 10 people with long-term mental illness. It is situated in a pleasant residential street in Watford within easy walking distance of the town centre, with all the community life that offers. The residents live relatively independent lives but with staff support always available when they require it and to monitor their general state of health and wellbeing. The home also offers two flats for more independent service users but these are excluded from the registered provision. The weekly placement fee for each service user is £ 670:69. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the first inspection for the inspection year 2006/7. The last inspection was unannounced and was undertaken on 6.02.06. Greenhill Lodge is one of a number of Care homes managed by the Mental Aftercare Association – a “Charitable Organisation”. It is registered to accommodate up to 10 younger adults with a long-term mental illness, who may have an associated physical disability and of both genders. On the day of the visit, there were 10 people in residence. This unannounced inspection took place during the early part of July 2006 and lasted for a total of 6 hours. During this visit, 5 service users and 4 staff members including the Registered Manager were spoken to, in order to seek their views regarding the quality of life for residents at Greenhill Lodge. A number of records were examined and a tour of the premises was also undertaken. What the service does well:
The inspection main finding is that 15 of the 21 Standards assessed on this occasion have been met There is a calm and friendly atmosphere at Greenhill Lodge with a lot going on in terms of interaction with staff and social activities. The residents are very positive about the support they receive from staff and describe them as being ‘very good’ and ‘helpful’. Residents receive appropriate support from a trained and consistent team of staff, who know the service users and are responsive to their changing needs. The service users spoken with felt involved in decisions about their care and support. The process for assessing and identifying the needs of any potential service user prior to being offered a place remains satisfactory; this ensures a greater degree of success so that the residents’ needs could be met on admission to the home. There is good evidence to show that the health and personal care needs are being identified through a care planning process and monitored internally through a monthly review system, involving the service user and their family where appropriate. The catering facilities appeared to be managed and delivered to the satisfaction of the resident group. On the day of the inspection, some of the service users were at home and others returned from day services; they appeared to be content, comfortable and received care in a manner conducive to good practice. Residents’ interests, expectations and aspirations are being sought to an extent and
Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 6 fulfilled satisfactorily. Service users are treated with dignity and respect, and their right to privacy is upheld. The staffing level is adequate to meet the identified needs of the current service users. The staff recruitment processes are adequately robust to ensure the safety of service users. All staff members have received mandatory training as appropriate, which is well valued by them. Formal supervision is offered to all staff and information gained from members spoken to confirm that it is a useful staff management system. The home has managed to retain most of its core staff members, hence generating a degree of consistency and continuity in the quality of service delivery. Staff members generally respond well to health and safety matters. What has improved since the last inspection? What they could do better:
There are 5 requirements and 1 recommendation arising from this report, which need addressing. It is crucial that a more holistic approach to care planning is adopted so that each care plan reflects the identified cultural and religious needs of the service user. Also, a system should be introduced to demonstrate clearly how the service user is being informed about their rights to confidentiality and access to records retained about them. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 7 In order to ensure a minimum standard with regard to the physical environment, phase 2 of the refurbishment programme must be progressed. All staff including seniors must have access to essential training in Adult Protection. In terms of health and safety, fire drills must be carried out once every three months, at minimum; hot water temperature must be maintained within the safety limit. 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. Greenhill Lodge DS0000019416.V302830.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 Greenhill Lodge DS0000019416.V302830.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, 3 and 4. The staff team including the Manager understand and appreciate the need to encourage and support the potential service user, their family and significant others to make an informed decision regarding the suitability of the services at this home. The offer of a reasonable “settling in” period is indicative that identifying needs and individual aspirations during the initial stage are central to a successful placement. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be good. EVIDENCE: Records examined and information gained from staff members and service users demonstrate that normally service users admitted to the home are under a Care Management arrangement and have a full assessment of needs by their respective Social Worker, prior to admission to the home. The Manager and an identified key worker from the home are involved in the pre-admission assessments, as well as other professional assessments from the referring agency. The establishment considers it to be “very essential” that the involvement of the prospective resident, family/relatives and significant others is central to the assessment process. Assessment records viewed are noted to be comprehensive. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 10 Staff including senior members of the management team reported and service users confirmed that prospective residents, their relatives/friends are always encouraged to visit and to “test drive” the home. The opportunity to meet with residents and staff members, and to undertake a tour of the accommodation, appear to be a routine part of the admission process at Greenhill Lodge. If a placement is offered and accepted, the initial visit/s to the home is followed by a trial period; a placement review would then take place with the service user, Social Worker, relatives and any other involved professionals to confirm the placement, assuming it remained suitable. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 10. The care planning and review processes ensure that the identified needs of the service user are addressed and unmet needs, closely monitored. The cultural and religious requirements of the resident must be woven in their care plan. Informing residents of their rights to confidentiality and access to records retained about them would be helpful. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be satisfactory. EVIDENCE: Information gathered from staff including two members of the management team and service users indicates that the needs of residents are being identified on an on going basis. A random sample of care plans for 5 service users were examined. Whilst there is a good level of information available, none of the care plans reflect the identified cultural and religious needs of these service users. This matter was discussed with the Deputy Manager and Manager and both are aware that remedial action must be taken. There is good evidence to show that there is an established internal review system in operation; each service user’s care plan is being systematically
Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 12 reviewed every three months to reflect changing needs and actions to be taken. Service users are encouraged and supported to make choices about their lifestyles and are very much treated as individuals. Service users said that staff consulted them about all aspects of their lives and they felt they had a reasonable level of personal control. Each resident has a key worker to provide extra individual attention and this system is felt to be effective. Staff members interviewed demonstrated a good knowledge of the needs of individuals. The wishes and feelings of service users who prefer not to mix with the others are respected and they are therefore able to spend their time as they choose. Evidence gathered suggests that staff treat information given by service users and significant others in confidence. Records regarding the residents are compiled and stored in accordance with the Organisation’s written procedures and the Data Protection Act 1998, and in their best interests. A system should however be instituted, in order to demonstrate that the service user is being informed about these issues and their rights of access to records retained about them. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 17. The service users appeared to be well supported to enjoy a full and meaningful life. The level and variety of social and recreational activities accessible appears to assist in the development and promote the welfare of service users. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be good. EVIDENCE: Progress records demonstrate that the service users have good access to the local community resources. Information available also suggests that the staff team and residents have worked very hard at building positive relationships with neighbours. The location of the home allows easy access to community facilities and shops. The town centre is nearby and offers a wide range of facilities including shopping and recreational activities. The care plans examined provide details of the social and recreational activities enjoyed by each individual service user. A weekly activities programme planned by residents with staff assistance is also available. Duty rotas are organised in such a manner, in order to ensure that staff are available in sufficient numbers to facilitate planned activities.
Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 14 Consistent with the last inspection report, there is one cooked meal served everyday. Meals are flexible and stringent eating times are not adhered to. Service users are able to eat together or may choose to eat alone. Residents have a reasonable diet, with individual preferences well known to staff and reflected in menu planning. Those asked reported that the food offered is good. Any eating disorder is referred to the psychiatric services and interventions agreed via the CPA meeting. Service users also have access to a Dietician, as appropriate. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Overall, information gathered from service users and staff members, and records examined indicate that the personal and health care needs of service users are being addressed well. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be good. EVIDENCE: There are a variety of dependency levels of service users; some live quite independently with staff assistance available as required; others need ‘one to one’ attention to achieve daily living tasks or to monitor their challenging behaviour. The varying levels of support required for each individual are well documented in their care plans. The Manager confirmed that all staff members are aware that any restriction must first be discussed with the service user, their Social Worker, family and significant others, before enforcement. He was also clear that any restriction imposed would be reflected in the resident’s care plan. Documentary evidence is available to show that good health assessments are undertaken with respect to individual service user. Visits from GPs and other health professionals are recorded. Identified health care needs are being addressed and good observations are maintained, in order to monitor and respond quickly to any change - as noted from the daily record of relevant occurrences.
Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 16 The home makes use of the “Boots Blister Pack” system for the administration of medicines. Evidence shows that staff members receive training before they are authorised to administer medicines. Two members of staff administer medicines together, in order to minimise any margin for error. There are currently 2 service users who self-medicate and appropriate risk assessments have been carried out by staff. The pharmacist visits regularly to monitor staff performance. Medicines are stored securely and their administration and disposal, accurately recorded. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The complaint procedures are accessible and service users and significant others should be adequately empowered to make a complaint. Essential training in Adult Protection would equip staff with the knowledge and skills and reinforce further, the existing systems for the safety of service users. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be good. EVIDENCE: Information regarding how to make a complaint is included in the service user’s guide and the home’s statement of purpose. Staff members interviewed including the Registered Manager reported that the procedures on complaints are available and accessible to residents, staff members and significant others. Members of staff interviewed demonstrated an understanding of the need to investigate, record all complaints and take action as required. Residents spoken to said that they feel able to make a complaint, if dissatisfied with any aspect of the service; the Manager has introduced a new book for the recording of informal ‘grumbles’, which contains several issues raised by service users. These appear to have been resolved to their satisfaction. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 18 The home uses the Hertfordshire procedures on Adult Protection. Staff members interviewed were not conversant with the procedures; they said that they had read the procedures but they need to revisit this subject. The Manager reported that all care staff members have received some training and an element of this is also covered in the induction package. Structured training on Adult Protection must be made accessible to all staff including senior members. There were no adult protection matters pending at the time of the inspection visit. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 19 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): The home and its surroundings offer a pleasant, comfortable and safe place to service users. Phase 2 of the redecoration programme would further improve the standards of the physical environment. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be satisfactory. EVIDENCE: A schedule of planned maintenance is kept that indicates progress made. The standard of furniture and fittings are adequate. Some parts of the accommodation are attractively decorated and furnished to a fair standard. Bedrooms are personalised to reflect the tastes and interests of the occupants, with gadgets, pictures and other personal effects. The service users confirmed their involvement in choosing colour schemes for their rooms. Bedrooms are lockable; on the day of the inspection many residents had locked their room before leaving for various activities. The communal areas are all decorated in bright colours and provide a homely living environment in which service users can relax and feel at home. However, considering the habits of some of the residents caused by their mental health difficulties, there is always a high level of wear and tear in this home. All of the current service users smoke cigarettes and inevitably the
Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 20 atmosphere in the communal areas reflected that. Consequently, some parts of the ground and first floor areas are nicotine stained and require redecoration. The completion of phase 1 (second floor in particular) of the upgrading programme has resulted in an improved standard of physical environment. Phase 2 of the refurbishment work (first floor) must be undertaken, in order to continue improving the standard of the physical environment. The neatly arranged garden provides an excellent alternative space for residents, especially in good weather. In addition to the flowerbeds there is a patio and a summerhouse. Staff members tend the garden, and occasionally service users help. A good standard of cleanliness was evident throughout those areas viewed. There were no mal-odours present. The laundry facilities are suitable and adequate for the service users’ group. The arrangements for the storage and collection of domestic waste remain satisfactory. There were no health hazards noted. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 21 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 and 36. The day and night staffing arrangements are deemed to be satisfactory. Staff recruitment process is robust and NVQ assessment for care staff is being given a higher profile. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be good. EVIDENCE: Staffing levels are deemed to be adequate to meet the needs of residents. Information gathered indicates that staff members have adequate experience and skills to enable them deliver a good quality service and care to service users. All staff received induction to the home and to the principles and practice of the specific nature of their work. They have also received all mandatory training and attended other courses relevant to their work. None of the care staff members have completed an NVQ course yet; it is however positive to note that 4 of the 5 permanent care staff members are currently undertaking their NVQ Level 3 (Deputy Manager doing NVQ 4) course. On completion, a ratio of 80 would be achieved. The National Minimum Standards states that a minimum ratio of 50 of care staff should complete NVQ Level 2 or equivalent. Whilst this standard is currently not met, evidence shows that NVQ assessment for staff is being given a higher profile.
Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 22 A recommendation is therefore not made, as it would serve no purpose in this case. The recruitment and selection processes for staff members remain adequately robust. The personnel recruitment files for 5 staff members were scrutinised and these are noted to be satisfactory. All 4 staff members including the Manager spoken to confirmed that normally they receive one to one formal supervision, once every 4 to 6 weeks. Supervision records are maintained. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 23 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): 38 and 42. The overall management of this home remains satisfactory. The health, safety and welfare of service users, and staff are being safeguarded; some attention is required regarding the frequency of fire drills and hot water temperatures. Records are maintained as required. Based on available evidence including a visit to this service, the quality in this outcome area is judged to be good. EVIDENCE: The Manager has successfully completed the NVQ Level 4 in Care and the Registered Managers Award in August 2005 and January 2006, respectively. This is most welcomed by the Commission. Staff members spoken to stated that they are very happy working at this home under the leadership of the Registered Manager. The Manager discussed the ethos of the home and the team’s efforts to ensure the home’s ethos benefits service users. Progress records and observation of staff interaction with the residents demonstrate that the homes ethos is put into practice. Action plans are drawn up for any shortcoming. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 24 Staff members receive ongoing training that ensures safe working practice. Disinfectant and cleaning materials are stored in locked cupboards and care is taken by staff members to ensure that residents are not exposed to any hazard. Mandatory training has been facilitated and risk assessments for each service user are in place. Fire equipment and the fire alarm system are serviced within the required frequency. Fire drills have been carried out but this must occur once every 3 months at minimum. Hot water temperature is tested daily; Records however indicate that temperature readings have been between 45 to 51 degrees centigrade on some occasions. The Manager is aware of these shortfalls and he has agreed to take remedial action. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 25 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 3 4 3 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 2 33 X 34 3 35 x 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x X 2 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 X 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x X 3 X X X 2 x Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 12 (4) & 15 (1) 13 (6) Requirement Care plans must reflect the identified cultural and religious needs of each service user. The Registered Person must ensure that staff receive essential training in Adult Protection Phase 2 of the maintenance/redecoration work (first floor) must be undertaken The Registered Person must ensure that fire drills are carried out once every three months, at minimum The Registered Person must ensure that remedial action is taken, in order to maintain hot water temperature within the safety limit. Timescale for action 15/09/06 2 YA23 15/10/06 3 YA24 23 (2) (d) 05/11/06 4 YA42 23 (4) (e) 05/10/06 5 YA42 13 (4) (c) 05/10/06 Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 27 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 YA10 Good Practice Recommendations A system should be instituted, in order to demonstrate more clearly that the service user is being informed about their rights to confidentiality and access to records retained about them. Greenhill Lodge DS0000019416.V302830.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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