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Inspection on 28/11/05 for Halland House

Also see our care home review for Halland House for more information

This inspection was carried out on 28th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Prospective residents have the opportunity to test drive the home. Residents have the opportunity to participate in meaningful, stimulating and appropriate activities. Supported annual holidays are provided for those who want them. Residents` personal relationships are facilitated. Residents` views and preferences are sought and they are listened to.

What has improved since the last inspection?

The processes and systems for recording residents care plans have been reviewed and all care plans are in the process of being updated. Staff recruitment procedures have improved and all the required checks are now completed prior to new staff being deployed to work in the home. A staffing review has been undertaken and each unit now has it`s own designated staff team.

What the care home could do better:

It is required that accurate records are kept in relation to when, where, how and by whom pre admission assessments are undertaken and preadmission information received. Visits made by or to prospective residents must also be recorded. It is a requirement that the goals set with residents are made in relation to the hopes and aspirations of each individual and not be based on personal care or other such routines. A timetable, reflective of the goals set, must be included on each individual`s care plan to illustrate his or her weekly activities. Guidance required by staff to enable them to support the individual to access or participate in their chosen activities must also be included along with any relating risk assessments. A requirement for guidelines to be written for staff to follow when supporting individuals in all aspects of their daily living was made at the last Inspection. The homes` two complaints policies and procedures should be consolidated into one document. A requirement for the complaints procedure to be reviewed was made at a previous Inspection. The Registered Manager is required to ensure that information relating to suspected incidents of abuse is passed on to the relevant social services assessment team without delay and that all staff receive training in relation to adult protection policies and procedures as specified in local guidance. It is recommended that the member of staff who witnesses or is the first to be aware of an incident of suspected abuse should make the initial contact with the assessment team. This should assist in ensuring the accuracy of the information relating to the incident and the context in which it occurred, as well as prevent any delays. Risk assessments are required to be undertaken for each resident in respect of the use of all areas of the home and grounds. Where risks are identified guidance must be provided for staff to follow in relation to how this risk is to be minimised. All areas of the home and grounds to which access is denied or restricted must be specified on the individuals care plan and the relevant guidelines must be in place. Requirements were made at the last Inspection for these risk assessments to be undertaken and must be completed without delay.

CARE HOME ADULTS 18-65 Halland House Halland East Hoathly East Sussex BN8 6PS Lead Inspector Elaine Green Announced Inspection 28th November 2005 10:00 Halland House DS0000021424.V252970.R01.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 Halland House DS0000021424.V252970.R01.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. Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Halland House Address Halland East Hoathly East Sussex BN8 6PS 01825 840268 01825 840630 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) Gary Richards Homes Limited Mrs Sonia Johanna Williams Care Home 30 Category(ies) of Learning disability (0) registration, with number of places Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. Date of last inspection 6th July 2005 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 accomodation 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 independant 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 stafff team. Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The National Minimum Standards refer to individuals who reside in Care Homes as “Service Users”. The people who live at Halland House would like to be referred to as “Resident(s)” so throughout this report the term “Residents” will be used. This Announced Inspection took place on the 28th November 2005 between 10 am and 5pm. As part of the Inspection the Registered Manager completed a Pre Inspection Questionnaire that provided the Inspector with statistical information relating to the home. Residents of Halland House and their relatives or representatives were also given the opportunity to complete comment cards and return them to the Inspector. On the day of the Inspection issues relating to the day-to-day running of the home were discussed with the Registered manager and her Deputy. Discussions also took place with five residents and five members of staff. A range of documents were examined including nine residents care plans, two recruitment files, a selection of the homes’ policies and procedures and a range of the homes daily records. What the service does well: What has improved since the last inspection? What they could do better: Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 6 It is required that accurate records are kept in relation to when, where, how and by whom pre admission assessments are undertaken and preadmission information received. Visits made by or to prospective residents must also be recorded. It is a requirement that the goals set with residents are made in relation to the hopes and aspirations of each individual and not be based on personal care or other such routines. A timetable, reflective of the goals set, must be included on each individual’s care plan to illustrate his or her weekly activities. Guidance required by staff to enable them to support the individual to access or participate in their chosen activities must also be included along with any relating risk assessments. A requirement for guidelines to be written for staff to follow when supporting individuals in all aspects of their daily living was made at the last Inspection. The homes’ two complaints policies and procedures should be consolidated into one document. A requirement for the complaints procedure to be reviewed was made at a previous Inspection. The Registered Manager is required to ensure that information relating to suspected incidents of abuse is passed on to the relevant social services assessment team without delay and that all staff receive training in relation to adult protection policies and procedures as specified in local guidance. It is recommended that the member of staff who witnesses or is the first to be aware of an incident of suspected abuse should make the initial contact with the assessment team. This should assist in ensuring the accuracy of the information relating to the incident and the context in which it occurred, as well as prevent any delays. Risk assessments are required to be undertaken for each resident in respect of the use of all areas of the home and grounds. Where risks are identified guidance must be provided for staff to follow in relation to how this risk is to be minimised. All areas of the home and grounds to which access is denied or restricted must be specified on the individuals care plan and the relevant guidelines must be in place. Requirements were made at the last Inspection for these risk assessments to be undertaken and must be completed without delay. 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. Halland House DS0000021424.V252970.R01.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 Halland House DS0000021424.V252970.R01.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. The quality of the pre admission assessment information is adequate however, the records kept in relation to this process are not. Prospective residents have the opportunity to test drive the home. EVIDENCE: The pre admission assessments/care plans for the two most recently admitted residents were examined. The manager explained that one of the prospective residents had visited the home on several occasions prior to moving in including an overnight stay and that his pre admission assessment had taken place over a three-month period. She stated that she had visited the previous placement on two occasions and another senior member of staff had made an additional visit. The quality and quantity of information gained about this resident was adequate however, there was no record of where or when these visits and assessments had been made or by whom. In the case of the other individual the manager explained that the pre admission assessment process took place over a three-week period. The quality of information received prior to this resident moving into the home was not as substantial and the manager explained that it has not been possible to gain any further information relating to this resident. A referral has been made to the Community Learning Disabilities Team in respect of having appropriate assessments undertaken and this was recorded. Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 9 It is required that accurate records are kept in relation to when, where, how and by whom pre admission assessments are undertaken and preadmission information received. Visits made by or to prospective residents must also be recorded. Halland House DS0000021424.V252970.R01.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): 6,7. Residents’ are supported to make decisions about their lives. Albeit the quality of care plans has improved, it is required that further information and guidance for staff to follow is included. EVIDENCE: A total of nine care plans were examined. The homes care planning processes and records have been recently reviewed and are in the process of being updated. Two members of staff stated that they felt the new system was working a lot better and provided them with clearer guidance as to how to support each resident. Each care plan contains the minutes of their last case review and of the residents’ current goals and how they are going to be achieved. Records for monitoring these goals are also kept in the care plan. The care plans examined that contained guidelines for staff to follow in relation to managing challenging behaviour, had been recently reviewed and updated. In one of the care plans examined the goals set were in relation to personal care and routines at mealtimes. It is a requirement that the goals set with residents are made in relation to the hopes and aspirations of each individual and not be based on personal care or other such routines. The quality of the information currently contained in the care plans is adequate. However, it is Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 11 required that a timetable is included on each individual’s care plan to illustrate his or her weekly activities. Guidance required by staff to enable them to support the individual to access or participate in their chosen activities must also be included along with the relating risk assessments. Halland House DS0000021424.V252970.R01.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): 12,13,14,15,17. Residents have the opportunity to participate in meaningful, stimulating and appropriate activities. Relationships are facilitated. The arrangement for the provision of food at meal times is adequate. EVIDENCE: Though information relating to leisure and activities is not currently included on individuals care plans it is evident that many residents lead active lifestyles. Discussions with four residents, management, four members of staff and the examination of records confirmed that residents have the opportunity to participate in a range of meaningful, stimulating and appropriate activities. The day care facility at the home is open every day including weekends when it can be accessed for recreational and leisure activities such as table tennis and pool. Residents also have the opportunity to access local colleges and social services day centres to which transport is arranged or provided. Trips out are organised at the weekends and some evenings. Supported annual holidays are provided for those who want them. Several residents spoke of recent visits they had had from family or friends and about their arrangements for visiting family at Christmas. Care plans Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 13 specify family relationships and peer group relationships pertinent to the individual. The Inspector joined a small group of residents for lunch. The food served was hot, homemade and nutritious. Residents participated in clearing the table, pouring their own drinks etc. This area dining area of the home is homely in character and the atmosphere during lunchtime appeared relaxed. Halland House DS0000021424.V252970.R01.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. Care plans adequately reflect residents’ preferences in relation to personal care. EVIDENCE: Two of the care plans examined included instruction and guidance for staff to follow in relation to residents’ preferences for how they receive personal care. In one of the care plans guidance in relation to individuals’ preferences for their personal care routine was clearly documented and in another, information relating to preferences re bathing routine was included. It is recommended that where the resident has no preferences in relation to how they receive their personal care that this too is documented. The homes’ new care plans include a section relating to personal presentation indicating individual likes to dress. Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. The homes’ complaints policies and procedures need to be reviewed and amended. Procedures relating to the Protection of Vulnerable Adults are not consistently followed. EVIDENCE: Currently the home has separate complaint procedures and policies for staff and residents. These were examined and found to be conflicting. It is required that these be consolidated into one policy and one procedure. It is disappointing to note that procedures in relation to making adult protection alerts are still not being followed consistently. At the Inspection records examined stated that during an outing a particular resident had presented with aggressive and challenging behaviour that had affected other service users. This information had not been passed to the manager of the home or a decision made in respect of whether to contact the local social services assessment team. In addition to this no review or further risk assessments were undertaken in respect of this individual participating in this activity and a subsequent outing to the same place resulted in similar but more serious incident occurring. Though this situation is now being managed appropriately by the home it is indicative of the fact that staff were not aware of the seriousness of these incidents. Further work is still required to be undertaken in the respect of staff training and ensuring that they are recognising adult protection issues when they arise and relating them to adult protection. In addition to this following the Inspection there had been a significant delay in the reporting of 3 incidents to the assessment team. The Registered Manager is required to ensure that information relating to suspected incidents of abuse Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 16 is passed on to the relevant social services assessment team without delay and that all staff receive training in relation to adult protection policies and procedures as specified in local guidance. It is recommended that the member of staff who witnesses or is the first to be aware of an incident of suspected abuse should make the initial contact with the assessment team. This should assist in ensuring the accuracy of the information relating to the incident and the context in which it occurred, as well as prevent any delays. Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is clean and hygienic. EVIDENCE: The areas of the home Inspected on the day were all found to be clean tidy and hygienic. The home employs domestic staff to undertake the majority of the cleaning tasks although residents and their key workers are responsible for Keeping bedrooms clean and tidy. Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 18 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): 31,32,33,34,35,36. Recruitment procedures are good and consistently followed. A recent review and reorganisation of staff has had a positive affect on service users and staff are appropriately supervised. Further training in issues of adult protection is required for all staff. EVIDENCE: Management and staff stated that there had been a reorganisation in the way staff were deployed in the home. The manager explained that some consultation had taken place with the staff team in relation to where in the home they would be allocated to work. Each unit now has a designated staff team and although they may be called on to work on other units to cover on occasions, on the whole they work with the residents on their designated unit. The staff explained that this had lead to more consistency in the way that support is delivered and that they feel they belong to a team. Four members of staff each stated that they felt the new system was better and was working well. It was also pointed out by three members of staff that key working was so much easier now that they worked with their key client on a regular basis. This in turn is having an affect on the consultation that occurs with the day centre on the appropriateness of activities that their key clients participate in. Each unit has a designated team of carers. Those staff that are more experienced and or qualified supervise the new, less experienced or qualified staff, these staff are also shift leaders. Their units’ senior in turn supervises Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 19 shift leaders and the Registered Manager in turn supervises them. All the staff spoken to stated that new staff are always shadowed initially and have to go through the home’s induction. Records relating to supervision were examined and confirmed that it was taking place regularly. Two recruitment files were examined and were found to contain all the relevant information and confirmation that all the require checks had been undertaken satisfactorily prior to them being deployed to work in the home. As previously stated within the report all staff must receive training in issues of adult protection with particular regard to reporting and recording suspected incidents of abuse. Discussions with staff indicated that there is still a level of confusion as to what needs to be reported and why. The home continues to work towards 50 of the care staff employed obtaining a National Vocational Qualification (NVQ) Level 2 or above in Care. The manager assured the Inspector that the current staffing levels could meet the needs of the residents. Feedback from some residents’ relatives indicated that this might not always be the case. It is recommended that the staffing levels be kept under review and adjusted as required. Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 20 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. Residents are benefiting from the improvements that have been made to the day-to-day running of the home and their views are being listened to. Further improvements are required in the respect of the protection and promotion residents’ health, safety and welfare. EVIDENCE: Residents are consulted on a range of issues at residents meetings, key worker meetings, annual and interim reviews and through the homes residents’ customer satisfaction survey. An examination of the minutes from a residents meeting was examined and confirmed that residents’ views had been sought. Risk assessments are undertaken in respect of tasks that individual residents undertake. These are contained within their individual care plans and the ones examined were found to be satisfactory. Further risk assessments are required to be undertaken for each resident in respect of the use of all areas of the home and grounds. Where risks are identified guidance must be provided for staff to follow in relation to how this risk is to be minimised. All areas of the Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 21 home and grounds to which access is denied or restricted must be specified on the individuals care plan and the relevant guidelines must be in place. Requirements were made at the last Inspection for these risk assessments to be undertaken and must be completed without delay. Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 22 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 2 X 3 X Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 3 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 2 2 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Halland House Score 3 X X x Standard No 37 38 39 40 41 42 43 Score x X 3 X X 2 x DS0000021424.V252970.R01.S.doc Version 5.0 Page 23 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 YA2 Timescale for action 14(1abcd) Accurate records must be 31/12/05 kept in relation to when, where, how and by whom pre admission assessments are undertaken. This also applies to any information received in relation to a prospective resident. 13(4b)15(1,2bc) Each residents care plan 30/03/06 16mn must contain a timetable to indicate the activities that they participate in. This should be reflective of their personal goals. Guidance for staff to follow in relation to how they are to support residents in participating in the specified activities must also be including any relating risk assessments. (Requirements for guidelines to be written for staff to follow when supporting residents in all aspects of their daily living were made at the last Inspection.) 22(1,2,3,6,7,8) It is required that the home 30/01/06 consolidates their two complaints policies and DS0000021424.V252970.R01.S.doc Version 5.0 Page 24 Regulation Requirement 2. YA6 3. YA22 Halland House 4. YA23 12(1a) 13(6) 37(1e) 5. YA31YA35 13(6) 6. YA32 19(5b) 7. YA41 13(4abc6) 15 23(o) procedures. (Requirements for the complaints policy to be reviewed were made at a previous Inspection.) The Registered Manager is required to ensure that information relating to suspected incidents of abuse is passed on to the relevant social services assessment team without delay. It is required that all staff receive effective training in relation to adult protection policies and procedures as specified in local guidance. It is required that a minimum of 50 of the care staff employed at the home obtain an NVQ Level 2 or above in care. Risk assessments are required to be undertaken for each resident in respect of their health safety and welfare when accessing any area of the home and grounds. Where risks are identified guidance must be provided for staff to follow in relation to how this risk is to be minimised and this must be documented on the care plan. 20/12/05 30/01/06 31/12/05 31/01/06 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 YA23 Good Practice Recommendations It is recommended that the member of staff who witnessed or was first aware of an incident of suspected DS0000021424.V252970.R01.S.doc Version 5.0 Page 25 Halland House 2. YA331 abuse makes the initial contact with the assessment team. Staffing levels are monitored and reviewed on a regular basis. Halland House DS0000021424.V252970.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Halland House DS0000021424.V252970.R01.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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