Inspection on 10/07/07 for Halland House

This inspection was carried out on 10th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Halland House 03/05/06

Halland House 28/11/05

Halland House 06/07/05

Halland House 20/01/05

Halland House 28/06/04

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

CARE HOME ADULTS 18-65 Halland House Halland East Hoathly East Sussex BN8 6PS Lead Inspector Nigel Thompson Key Unannounced Inspection 10th July 2007 09:30 Halland House DS0000021424.V343203.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 Halland House DS0000021424.V343203.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. Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Halland House Address Halland East Hoathly East Sussex BN8 6PS 01825 840268 01825 840630 mail@garyrichardhomes.co.uk www.garyrichardhomes.co.uk Gary Richard Homes Limited 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) Mrs Sonia Johanna Williams Care Home 30 Category(ies) of Learning disability (30) registration, with number of places Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is thirty (30). Service users will be aged eighteen (18) to sixty five (65) years on admission. That service users will have a learning disability. That one named service user who was over the age of sixty five (65) on admission can be accommodated. 3rd May 2006 Date of last inspection Brief Description of the Service: Halland House is situated on the main Eastbourne to Uckfield road in the village of Halland. There are two public houses within walking distance and a bus service providing links to the towns of Eastbourne, Lewes, and Uckfield. The home provides accommodation for up to 30 adults with a learning disability. The property is divided into three areas, a large detached house with two floors and a smaller lodge where the most independent residents live. The lodge has its own kitchen but main meals are prepared in the house. There are large gardens providing an area for relaxation and recreation as well as an area for a gardening project. There is a day centre within the grounds which some of the service users attend and it has a dedicated staff team. The residential fees charged are assessed on an individual basis starting from £520 per week and day care is charged at £30 per day. Copies of the most recent Inspection report are available form the provider upon request. Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over five and a half hours in July 2007. It found that the majority of the key National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users observed and spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. On the day of the inspection there were six service users living at the home. The inspection involved a tour of the premises, observation of working practices, examination of the home’s records and discussion with three service users, three members of staff, the assistant manager and the Registered Provider. Responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. The focus of the inspection was on the quality of life for people who live at the home. What the service does well: Service users at Halland House clearly benefit from having an experienced manager and dedicated staff team who are evidently committed to providing consistent and high quality care. Staff work closely with service users and have developed a sound understanding of their individual care and support needs. The relaxed, homely and welcoming environment has evolved over many years and reflects the commitment within the staff team and the open and inclusive management style. Service users are encouraged and supported to make decisions about their lives. They are involved and regularly consulted on many aspects of life in the home, including menu planning and activities. Staff receive effective induction and foundation training, regular supervision and are clearly valued and supported by the management team. Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Halland House DS0000021424.V343203.R01.S.doc Version 5.2 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 Halland House DS0000021424.V343203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The thorough admission policy and procedure ensures that service users are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective service users know that the home is able to meet their individual care and support needs. EVIDENCE: Although there have been no service users admitted to Halland House since the previous inspection, comprehensive information relating to the home is made available to all prospective service users, their relatives and associated care managers. As well as an informative website, detailing facilities and services provided, documentation including an updated Statement of Purpose ‘ and ‘Service User Guide’ was examined and found to be satisfactory. Clear admission criteria and a thorough pre-admission assessment of each prospective service user, which incorporates a comprehensive breakdown of all Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 9 personal, emotional and social care needs, ensures that all identified needs can be met. The manager confirmed that Halland House continues to maintain a good working relationship with the local Community Learning Disability Team (CLDT), who consequently have a sound understanding and awareness of the suitability of the home and the range and quality of the services provided. A referral to the home from the CLDT consists of a thorough Social Care Assessment and any additional relevant reports. The manager or assistant manager will also visit the prospective service user and carry out a full preadmission assessment, including any personal and emotional care and support needs, mobility issues, social and cultural needs and family involvement. In addition to establishing whether the individual’s care and support needs can be met within the home, the assistant manager also stressed the importance of ensuring compatibility with existing service users. As well as being invited to visit the home to look around and meet with existing residents and staff, prospective service users have the opportunity to stop overnight or occasionally for a weekend stay before moving in. The assistant manager confirmed that all new service users undergo a one month trial period at the home, followed by a thorough placement review, during which time their suitability and compatibility are fully assessed and it is established whether their identified care and support needs are able to be met. Halland House DS0000021424.V343203.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users’ care plans enable staff to meet assessed needs in a structured and consistent manner. However individual plans, including risk assessments do not always reflect changing support needs. Systems for consultation and participation remain effective and service users are treated with respect and encouraged and enabled to make decisions about their day-to-day living. EVIDENCE: Staff spoken to during the inspection confirmed that, despite the variable and limited verbal communication of many service users, effective and regular interaction and consultation takes place constantly throughout the home. This was evident from direct observation of staff supporting service users in a professional, sensitive and respectful manner. Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 11 The assistant manager confirmed that service users and, where appropriate, a relative or representative have the opportunity to be involved in care plan reviews. In plans that were examined, it was evident that recent reviews had taken place, however, in each case there was no record of who had been present at the review. Much of the relevant documentation, including behaviour guidelines, daily schedules and personal risk assessments, was also undated. There was therefore no documentary evidence of when information had been updated and whether plans accurately reflected the individual’s current or changing needs or circumstances. It was noted in one service user’s care plan that was examined that there was no documentary evidence of changes made to reflect recently developed guidelines, following a case review held in May this year. Although comprehensive ‘pre-review’ notes are evidently produced it was noted that the ‘after case review’ minutes were generally very brief and far less detailed and contained no information regarding specific outcomes or action points. As discussed with the assistant manager it is recommended that individual care plans be reorganised to help ensure that all necessary information is collated more concisely and is consequently more readily accessible. Independence and individuality is evidently encouraged and promoted within the home and is reflected in the personalising of service users’ rooms, the choice of bedclothes and colour schemes and individual preferences for occupational and leisure activities. Halland House DS0000021424.V343203.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are enabled and supported to maintain contact with family and friends as they wish and effective links with the community enrich their social and educational opportunities. Service users benefit from appropriate recreational and leisure activities and menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: The recreational and leisure interests of service users are identified and recorded in their individual care plan and they continue to be supported to access activities and facilities, reflecting their individual needs, preferences and abilities. Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 13 An ‘Occupational Activities’ programme has been developed for each service user and a meeting is held each Friday to discuss and plan the activities for the following week. Community participation remains a focus in the home and service users are evidently encouraged and supported to visit the cinema, theatre, local shops and other amenities. The assistant manager confirmed that, where appropriate, service users’ family links are encouraged and supported, however not all service users have regular family contact. Visiting to the home is largely unrestricted and relatives and friends are made welcome at any reasonable time. Menus are varied and balanced and are based on service users’ identified likes and preferences. An alternative to the main meal is always available and a copy of the menu is displayed on each unit. The assistant manager confirmed that service users are not generally involved in meal preparation. Halland House DS0000021424.V343203.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff have developed close and positive relationships with service users and demonstrate an awareness and sound understanding of their individual care and support needs. Service users are protected by clear and comprehensive policies and procedures in place for the control and safe administration of medication. EVIDENCE: As previously documented, despite the limited and variable communication skills of service users, staff evidently work closely and sensitively with individuals to develop effective levels of interaction. Documentary evidence was in place to demonstrate that the health and emotional care needs of service users continue to be met within the home. Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 15 All service users are registered with local GPs and have access to other health care professionals, including district nurses, physiotherapists and dentists, as required. It was noted, in individual care plans that were examined, that all appointments with, or visits by, health care professionals are recorded. Up to date and detailed policies and procedures relating to the control, storage, administration and recording of medication are in place. Medicines are stored and recorded appropriately. All staff responsible for administering medication have received training and are individually assessed and authorised to do so. The assistant manager confirmed that, following risk assessments, no service user currently self-administers their own medication. Halland House DS0000021424.V343203.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home’s complaints procedure ensures that service users, staff and visitors feel able to express any concerns, confident that they will be listened to and acted upon. Service users are protected, through policies and procedures relating to abuse and adult protection. EVIDENCE: For the benefit of service users living in the home, a simple illustrated complaints procedure has been developed, with the use of symbols. The assistant manager confirmed that due to the variable levels of mental capacity among the service users, it is unclear as to the individual awareness or understanding of the process. Close working relationships, effective communication and consultation provide adequate opportunity for any concerns to be raised and discussed, before they become complaints. Following discussion with the Provider and assistant manager, the current complaints procedure is to be reviewed and redeveloped in a more simple and concise format, to include timescales and updated contact details for the CSCI. Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 17 Service users and members of staff, spoken with during the inspection, confirmed that they would have no hesitation in speaking to the manager or making a complaint if necessary and each person was confident that they would be listened to: ‘The manager has an ‘open door’ policy and is always helpful and very approachable’. Detailed policies and procedures are in place relating to adult protection and abuse, including a whistle blowing policy. The acting manager confirmed that all staff have undertaken specific adult protection training, in accordance with the multi agency guidelines for the protection of vulnerable adults. This was supported through discussions with members of staff during the inspection and evidenced through individual training records. Halland House DS0000021424.V343203.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The service is accessible, safe and clean and remains clearly suitable for it’s stated purpose. Service users benefit from all necessary specialist equipment and pleasant accommodation that is comfortable, well maintained and decorated to a satisfactory standard. EVIDENCE: New kitchens have been fitted in each unit and the boundary fence has been replaced. Other than this there has evidently been little change in the physical environment of the home since the previous inspection and overall standards remain satisfactory throughout. During my ‘guided tour’ of the premises, including service user accommodation and spacious communal areas, it was evident that the well maintained décor Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 19 and adequate furniture and furnishings continue to provide a comfortable, pleasant and homely environment for service users. It was evident that many of the service users’ rooms have been personalised, with pictures, family photographs and other possessions and small items of furniture, to reflect individual taste, choice and interests. Each of the three areas of the home has its’ own lounge area. These are homely in character. New leather sofas and armchairs have been purchased providing ample seating for the number of residents who reside there. Service users and their key workers continue to be responsible for keeping bedrooms clean and tidy and contract cleaners are employed for other areas of the home. On the day of the inspection, levels of cleanliness and hygiene throughout the home were found to be satisfactory Halland House DS0000021424.V343203.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 &36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There is always sufficient trained and competent staff on duty to meet the assessed needs of the service users. Service users are protected by satisfactory staff recruitment policies, procedures and documentation. EVIDENCE: From the staff rotas examined and through discussion with the assistant manager and care staff, it is evident that sufficient staff are employed to meet the current assessed needs of residents. Each member of staff is assigned to a particular unit, ensuring consistency and continuity of care. The assistant manager confirmed that staffing levels are closely monitored and are directly linked to service users’ levels of dependency. All newly appointed staff undertake a comprehensive induction programme the ‘Common Induction Standard’, which is compatible with Skills for Care Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 21 (Formerly TOPSS) and is flexible and compatible with an individual’s level of relevant experience. The assistant manager also confirmed that appropriate core skills training is provided, including first aid, moving and handling, food hygiene and fire safety. This was confirmed through discussions with staff and supported by effective training records examined: ‘There are plenty of opportunities for training here’. The assistant manager confirmed that there are currently eleven members of staff who hold the National Vocational Qualification (NVQ) level 2, or above. This represents 53 of all care staff in the home. More staff are currently working towards this award. In accordance with company policy, the assistant manager confirmed that formal supervision is provided for all care staff on a regular basis. The home operates a ‘cascade’ system with all care staff receiving supervision from a senior care officer. All senior staff, including the occupational activities manager and the assistant manager receive their supervision from the registered manager. This was evidenced by effective supervision records examined and through discussions with staff, spoken with during the inspection, who acknowledged the benefits of effective supervision and confirmed feeling valued and supported by the senior staff, manager and assistant manager: ‘Supervision is good. I find it very useful and the manager is always very supportive’. It is evident, from discussions with members of staff that the manager also operates an ‘open door’ policy, with staff feeling confident and able to discuss any issues at anytime. The manager is clearly aware of the need for thorough and robust recruitment procedures, to ensure the protection of service users. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. Halland House DS0000021424.V343203.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from a competent and experienced manager and are protected by satisfactory health and safety procedures. However their best interests are not always safeguarded by inadequate and ineffective quality monitoring systems. EVIDENCE: Through discussions with service users and members of staff, it is evident that the manager continues to demonstrate a clear sense of leadership and Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 23 direction. She is clearly motivated, positive and approachable and continues to create an open and inclusive atmosphere within the home. Although it is evident that ‘Picture mapping’ has recently replaced service users’ satisfaction questionnaires, quality assurance systems generally are inadequate and unsatisfactory. Despite reassurances in the Statement of Purpose that: ‘We regularly ask for comments on the home, the staff and the services we provide’, it is evident that the views of service users’ relatives and other stakeholders are not formally being sought at present. The assistant manager confirmed that the health, safety and welfare of service users and staff remain of paramount importance within the home. As previously documented, staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. All staff training is satisfactorily recorded. COSHH assessments and guidelines are in place. Regular fire drills are undertaken and recorded. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. Halland House DS0000021424.V343203.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 3 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 15 (1) & (2) Requirement Timescale for action 30/09/07 2. YA9 3. YA22 4. YA39 It is required that, where appropriate, each service user, or a representative, be involved in the development and reviewing of their individual care plan. 13(4b)15(1,2bc)16mn It is required that service users’ individual care plans, including risk assessments, be regularly reviewed and updated to reflect changing needs. (Previous timescale of 30.06.2006 not met). 22(1,2,3,6,7,8) It is required that the home’s complaints policy and procedure be reviewed and amended to specify timescales and updated contact details for the CSCI. (Previous timescale of 30.06.2006 not met). 24 (1) & (3) It is required that systems for regularly reviewing and improving the quality of DS0000021424.V343203.R01.S.doc 30/09/07 30/09/07 30/09/07 Halland House Version 5.2 Page 26 care provided in the home be developed and implemented, including seeking the views of service users and their representatives. 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 YA6 Good Practice Recommendations It is recommended that individual care plans be reorganised to help ensure that all necessary information is collated more concisely and is consequently more readily accessible. It is recommended that policies, procedures and documentation contained in service users’ care plans including staff guidelines and individual risk assessments be signed and dated. It is recommended that, as discussed, the current complaints procedure be reviewed and redeveloped in a more simple, concise and accessible format, 2. YA6 3. YA22 Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Halland House DS0000021424.V343203.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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