Inspection on 18/03/06 for Harleith

This inspection was carried out on 18th March 2006.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Harleith 17/07/06

Harleith 25/07/05

Harleith 22/02/05

Harleith 05/10/04

Harleith 15/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Harleith 42 Grand Avenue Southbourne Bournemouth Dorset BH6 3TA Lead Inspector Sophie Barton Unannounced Inspection 18 March 2006 09:00 th DS0000003945.V287015.R01.S.doc Version 5.1 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 DS0000003945.V287015.R01.S.doc Version 5.1 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. DS0000003945.V287015.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Harleith Address 42 Grand Avenue Southbourne Bournemouth Dorset BH6 3TA 01202 426544 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 Stable Family Home Trust Mrs Samantha Irene Habgood Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000003945.V287015.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The manager must complete NVQ Level 4 in care by 31st December 2005. 25th July 2005 Date of last inspection Brief Description of the Service: The registered service provider is the Stables Family Home Trust [S.F.H.T] a charity that provides residential care, a day service and related services for adults with learning disabilities. The day and residential services are interdependent with support from specialist staff at the day service being available to the staff and service users in residential care. The day service staff provide training, guidance and help with among other things matters such as employment, risk assessments and personal relationships. The home is located in a residential street in the Southbourne area of Bournemouth, within easy walking distance of local amenities that include, cliff top walks, a beach, shops, cafes, restaurants, post office and places of worship. Public transport is readily available and Bournemouth town centre a ten-minute bus ride away. The accommodation provides for up to eight people in a large detached threestory house converted for use as a residential care home. Service users bedrooms are located on the first and second floors of the premises. The home is centrally heated and all residents have single rooms, and the use of a shared lounge, dining room, kitchen and laundry facilities. To the rear of the property there is a garden with a paved patio area, a brick built barbeque and garden seats. At the front there is a large parking area. DS0000003945.V287015.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days. The first visit was unannounced on a Saturday morning, the 18th March 2006. The second visit was announced and was on the morning of Monday 27th March 2006. On the first day the inspector was shown around the home by a service user. The inspector also spoke with a group of five service users privately. Detailed discussions took place with the manager on both days. Two staff members were seen but not spoken with privately. Three care files were examined, as well as staff recruitment and training files, health and safety records, complaints log, incident records and some policies and procedures. Twenty standards have been assessed at this inspection, covering thirteen of the key standards. What the service does well: What has improved since the last inspection? The manager has completed the Statement of Purpose and Service User Guide. Both these documents are suitable and ensure that prospective service users have good information about the home. The guide is user friendly, and the current service users helped in developing it. DS0000003945.V287015.R01.S.doc Version 5.1 Page 6 Work is also being carried out on improving the care plans and risk assessments for service users. The draft plans seen are thorough and informative. New risk assessments are being written for each service user. This will ensure that all service users have up to date care plans, and clear guidelines for staff to follow. The manager has also helped service user understand what information is kept about them, and what staff record. Recently the staff were efficient and competent in dealing with an adult protection issue. There is now only one staff vacancy, with six posts now covered by permanent staff. It is hoped that this will offer consistency of care and that service users can begin to build up relationships with the staff team. Work has begun on refurbishing the bathrooms. However, continued improvement is needed to ensure that the bathrooms are comfortable and at an acceptable standard. 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. DS0000003945.V287015.R01.S.doc Version 5.1 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 DS0000003945.V287015.R01.S.doc Version 5.1 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): 1 and 5 (Standard 2 is not applicable at this time) Prospective service users are enabled to make a positive choice about where they would like to live, by being provided with good user-friendly information about the home. Some improvement is needed to the contract written by the home, so that service users have full information about the terms and conditions of residency. EVIDENCE: The manager showed the inspector the Statement of Purpose and Service User Guide for the home. These are both kept in the hallway, accessible for staff, service users and visitors. One service user informed the inspector that they had helped to write and take pictures for the documents. Both documents included the areas detailed in the regulations, and were informative and clear. The manager stated that she is hoping to arrange an audio version of the Guide to be produced. A user-friendly statement of terms and conditions (contract) has also been developed. Files examined by the inspector showed that service users have signed the document and agreed to it. The contract is well written and related to the services provided at Harleith. Unfortunately the fees charged to service users, and those paid by funding authorities, is not specified. The manager stated that feedback from service users was that this information is not wanted. There needs to evidence that this is the case for each individual. DS0000003945.V287015.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 and 10 Care planning documentation is detailed, person-centred and informative, ensuring service users and staff are fully aware of how needs and goals are to be met. Better risk management strategies are now in place, with clear strategies documented to minimise risk and promote independence. Staff respect service users right to confidentiality, with information about service users handled appropriately. EVIDENCE: The inspector examined three care files. The home has developed for each service user an Essential Life Plan which covers a range of needs including health, personal care and independent living skills. These plans seen were dated 2004. Annual reviews had taken place, which again covered a range of needs and were written in a user-friendly style. Some service users also had Person Centred Plans which were more general and detailed the service users goals and aspirations. Although informative about the service users needs and wishes, these plans did not detail how the staff are to meet the needs and goals. The manager was aware of this and showed the inspector “Support Plans” that were in the process of being written for each service user. These DS0000003945.V287015.R01.S.doc Version 5.1 Page 10 detailed the action needed by staff on a daily basis to ensure the service users needs were met and appropriate support given. No current system is in place for reviewing care plans more often than yearly, but again the manager is considering monthly key worker meetings to meet this good practice recommendation. The manager and staff are currently in the process of reviewing and completing up to date risk assessments for each service. The staff recently undertook training in risk assessment. Some of the new risk assessments were seen and these were detailed. They confirmed that service users independence is to be promoted with support and training put in place to minimise risks. Assessments seen were for being unsupervised in the home, cooking own meals, managing own finances. Guidelines relating to behaviour management were also seen on service users files, ensuring staff act consistently and in the service users best interests. Each service user had input into their ‘care plans’, with service users encouraged to sign documents and comment. Service users agreed that they can have access to their files and helped to understand what is being written about them. The manager has developed a written form explaining to service users and representatives the information that is kept about them. Written documentation seen by the inspector concerning a recent incident within the home, evidenced that staff are aware of when information about a service user has to be shared with others. DS0000003945.V287015.R01.S.doc Version 5.1 Page 11 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): 11, 15 and 16 The service users are supported well by staff in maintaining appropriate personal and family relationships. The home actively promotes individual choice and provides opportunities for personal development. However, house routines need to better balance the wishes of service users against those of staffing and management issues. EVIDENCE: Service users informed the inspector that they can have friends to visit at any time. The inspector was informed that friends can stay overnight or for dinner. Privacy is respected by staff with service users having keys to their bedrooms and they confirmed that staff do not enter their rooms without permission. One service user stated that staff are helping him to go away for the weekend with his girlfriend and their family. Service users were observed using the house phone for personal calls. Discussion with service users also confirmed that they attend social clubs and meet with other people outside of the home. Care planning documentation evidenced that service users are helped by staff to develop appropriate personal relationships. DS0000003945.V287015.R01.S.doc Version 5.1 Page 12 The house routines promote independence. Some of the service users have their own food budget, so they plan, shop and cook their own meals. All service users are encouraged to prepare their own snacks and service users were seen preparing lunch and drinks on the day of the inspection. Care plans set out the support needed for service users to undertake household tasks (cleaning, laundry). Service users were observed spending time in the communal areas and opting to be alone in their rooms. Staff were seen interacting well with service users. However the service users did comment that staff interacted less with them, and spent time in the office with the door shut. The service users also commented that their dining room was often used for staff meetings, and they would prefer that this wasn’t the case. The dining room should instead be used for breakfast and using the computer. The manager is addressing these concerns with the service users. Another concern raised by a service user is the lack of input he has received for using his kitchenette. He has been waiting for a key worker to undertake some training with him. The manager confirmed that there has been a delay, but that this is now being actioned. The inspector was informed that two service users are due to move into more independent living. One service user was receiving extra hours of support each week in independent life skills training and developing a support plan for when she moves. Both service users were considerably pleased with the support they were receiving from the home to enable them to move on. Only one service user receives advocacy support. The other service users were not familiar with advocacy. DS0000003945.V287015.R01.S.doc Version 5.1 Page 13 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 and 19 The staff have a very good understanding of the service user personal care support needs, promoting consistency and maximising privacy, dignity and independence. Service users are supported well to manage their own health care needs which is good practice. However, improvement is needed in the recording of health issues, to ensure that health needs are monitored and dealt with effectively. EVIDENCE: The ‘Essential Life Plans’ and the new ‘Support Plans’ detail the service users personal care needs and how the staff are to meet these needs. They are detailed and include daily routine of washing, dressing, toileting and dental hygiene. The plans evidence that the support offered complies with the preferences of the service user and is aimed at maximises privacy, independence and dignity. On the day of the inspection the service users had their own routines they were following. One service user had got up early to go surfing, one was off to the shops and the others were still in bed. Care files seen showed that staff have helped refer service users to specialist services (physiotherapy, psychiatry) where appropriate. Recommendations from specialist professionals have been included in the home’s care planning (for instance physio plans). Staff attend outpatient appointments with service DS0000003945.V287015.R01.S.doc Version 5.1 Page 14 users. The outcome of appointments/tests are now being recorded more appropriately so that staff can monitor outcomes. The Personal Health Records for each service user have not been completed in full, and therefore there is vital information missing from these documents. One service user has epilepsy. No guidelines were seen for the action staff are to take following a seizure. The manager confirmed that this is currently being arranged with the community nurse. Service users have been assessed in relation to administering their own medication. Risk assessments document how this is to be managed. Service users are also encouraged to see health professionals privately, and are all registered with their own choice of GP. Standard 20 was not assessed in full. However, the inspector did note that the medication administration records were not being completed appropriately by staff. The manager addressed this with staff immediately and therefore will be reviewed at the next inspection. DS0000003945.V287015.R01.S.doc Version 5.1 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 and 23 Complaints from service users are listened to and acted on efficiently, ensuring service users have a say about their care. Staff have a good understanding of adult protection issues, which helps to safeguard service users from abuse. EVIDENCE: Since the last inspection there have been three complaints made to the home. Two were unsubstantiated. They were dealt with quickly and thoroughly with the outcome clear to the complainant. The service users have easy access to complaint forms, and aware that these forms can be given directly to the Director of the organisation. The home has a detailed policy and procedures that meet the good practice recommendations and regulations. During the inspection, the service users did express concern that they did not feel confident to raise complaints with the manager. They raised a number of concerns with the inspector about care practices within the home (staff accessibility and lack of communication, few outings arranged, limited transport). The manager was informed of these complaints and they were addressed within 2 weeks. The manager and director met with the service users. The manager then arranged a brain storming session with service users expressing how things had changed, why, and how could they be done differently. This session was user-led and clearly evidenced that service users views were valued and listened to. The manager has recently undertaken a ‘training for trainers’ course in protecting vulnerable adults. There are clear and informative adult protection policies and procedures for the home. Staff have received training in this area. There was a recent adult protection investigation initiated by the home. Staff followed appropriate procedures and liaised closely with the statutory agencies. Services users were supported well through the process. DS0000003945.V287015.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 and 30 The standard of decoration and fixtures remains poor, with continued improvement needed to ensure that service users have a comfortable place to live. However, the home is clean offering service users a hygienic environment. EVIDENCE: On the day of unannounced inspection the home was clean and tidy. The inspector had a tour of the premises (excluding six bedrooms). The fridge and freezers are maintained satisfactory and safe procedures followed for food preparation and storage. The communal areas and bathrooms were clean with no offensive smells. There is a separate laundry room which is away from food preparation areas. The communal lounge is furnished well with ample comfortable seating. The dining room also provides ample space for eating and recreation. The service users are awaiting blinds for this room. The manager confirmed that the bathrooms and toilets are being refurbished. At present they do not provide a comfortable or pleasant place to be. There is black mould on the ceilings and the floor in the second floor bathroom is stained. The window will not shut in this bathroom which leaves the room very cold. There was no soap in either bathrooms and no lampshades in the landing. The two bedrooms seen provided ample space for personal belongings and they were furnished and decorated to the service users tastes. DS0000003945.V287015.R01.S.doc Version 5.1 Page 17 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): 33, 34 and 35 Staffing changes has led to some instability. Recent recruitment however should allow for the team to become more cohesive and effective at meeting service users needs. Staff training is given priority within the home, to ensure that service users benefit from a qualified staff team. Minor improvements are needed to the recruitment information obtained to evidence that service users are protected by safe recruitment procedures. EVIDENCE: There has been a whole new staff team in the last year, with two members of staff starting in post this month and one post still vacant. The service users confirmed that they did not yet feel they knew staff well. They also stated that the staff team did not provide as good a level of care as the previous staff did. On the day of the unannounced inspection there were two staff on duty. One had been in post for two weeks and one was a bank worker. The manager was due on duty later on in the day. Service users were however being supported to carry out their normal routine (going to the bank, for a massage, shopping). The service users concerns regarding staffing were being addressed at the time of the inspection with the manager. DS0000003945.V287015.R01.S.doc Version 5.1 Page 18 The home has historically not provided staff support during the hours of 9am and 5pm. This is because the service users attended day care outside of the home. However, service users needs and wishes have changed and service users are requesting more flexible day opportunities. The manager has responded to these requests and some staffing support is now offered in the home. Two members of staff provide support in the evenings and at weekends. This allows for service users to be supported outside the home for activities and social events. The staffing levels are assessed as being appropriate for the needs of the service users. The inspector examined the staffing files. The records included copies of references, application form and copies of identity (passport, driving license). On two files there were only one reference obtained. The manager confirmed that the other reference will be kept at Head Office. Criminal Record Bureau certificates were also not being kept routinely in the home, but instead the number of the disclosure recorded. Verbal checks of references were not recorded in the home’s file. The inspector noted gaps in a member of staffs employment. This had not been addressed during the recruitment process. A member of staff told the inspector that the interview process was formal and thorough. She did not start work in the home until her CRB heck had been received. There are currently six members of staff, and the team is well qualified and experienced. Two members of staff have an appropriate degree, another A levels. One member of staff has an NVQ 2 in care and two members of staff are registered to undertake this course shortly. Three members of staff have completed the Learning Disability Award Framework training. The manager has devised a training/ personal development record for each member of staff. Training is also covered in supervision sessions. The training recorded for one member of staff included first aid, infection control, manual handling, health and safety, induction and foundation, medication, food hygiene, risk assessment and oral health. The training forecast for 2006-7 also included epilepsy training. DS0000003945.V287015.R01.S.doc Version 5.1 Page 19 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): 37, 39 and 42 Service users views do not underpin the formal review of the home’s practices, which limits the effectiveness of the quality assurance systems. Health and safety systems need to improve to ensure that the environment remains safe for service users. The home’s manager is experienced and qualified and is competently meeting the home’s stated purpose, aims and objectives. EVIDENCE: Since the last inspection the manager has been registered with the Commission. The manager is able and experienced to manage the home. She has an appropriate qualification (NVQ 4 and a degree in psychology) and has worked for a number of years with adults who have a learning disability. Since the last inspection she has addressed a number of requirements and recommendations. DS0000003945.V287015.R01.S.doc Version 5.1 Page 20 The health and safety records were examined. The fire precaution systems are services quarterly by a specialist company. The staff also carry out weekly visual checks. The fire risk assessment is dated 2006. The records of fridge, freezer and food temperatures evidence that these are taken regularly. There are clear hazard analysis sheets kept for hazardous substances, and safe working practices risk assessments. Staff receive training at the Day Services offices every six months by a qualified person. The manager then carries out informal training in the home three monthly. There are no details of what is involved in this training. Fire drills are carried out every two months, and these have all been done in the evening between 18:30 and 21:30. It is necessary for a drill to be carried out at night or the early hours when the night staff member is on duty by themselves. Another area where improvement is needed is in relation to water temperature checks. These are done monthly. However there were many incidents when the temperature was recorded as being over 45 degrees centigrade and under 40 degrees centigrade. There was no record made of whether this fault with the thermostats was rectified. DS0000003945.V287015.R01.S.doc Version 5.1 Page 21 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 N/a 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 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 X 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 3 LIFESTYLES Standard No Score 11 2 12 X 13 X 14 X 15 3 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 x X 3 X 1 X X 2 X DS0000003945.V287015.R01.S.doc Version 5.1 Page 22 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. Standard Regulation Requirement The registered provider must develop an annual plan for the home in order that the success in achieving the aims and objectives set out in the Statement of Purpose can be measured. Timescale for action 1 YA39 24 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard YA5 Good Practice Recommendations It is recommended that the draft contract includes more detail about the fees to be paid, by whom how and when. If service users request that this information is not provided in the contract this needs to be recorded. Work should continue on finalising the support plans for each service user. Service user care plans should be reviewed at least every six months. Service users should be given more support to use their kitchenettes. The dining room should not be used for staff meetings DS0000003945.V287015.R01.S.doc Version 5.1 Page 23 1. 2. YA6 3. 4. YA11 YA16 when service users are at home. The spare room should be used more for staff business. The manager should agree an action plan with service users around the use of the office. Service users should be informed of advocacy support, and enabled to contact an advocacy service if necessary. The personal Health Records for service users should be completely more comprehensively. The fixtures and decoration within the home should be maintained at an appropriate standard. The manager should provide the Commission with a copy of the action plan developed following the service users concerns about staffing practices. There needs to be an agreed procedure with the Commission about where the recruitment information is to be stored for employees. Criminal record Bureau checks should be kept until an inspector has viewed them. Gaps in employment should be addressed for each applicant, and the discussion recorded. The corporate policy on quality assurance and review needs to be developed further to include how feedback is to be sought from other interested parties, including service users. It is recommended that the registered provider should produce written policies and procedures for all the topics set out in Appendix 2 to the National Minimum Standards (2nd Edition) and these should be produced in relevant formats for service users where appropriate. This recommendation was not assessed at this inspection. The record of fire training for staff needs to include details of the content of the training. Fire drills should take place at night or early morning. Water temperature records should include a record of how and when the fault was rectified. 5 6 7 YA19 YA24 YA33 7 YA34 8. YA39 9. YA40 10 YA42 DS0000003945.V287015.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000003945.V287015.R01.S.doc Version 5.1 Page 25 - 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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