Inspection on 26/10/05 for Leigh Bank

This inspection was carried out on 26th October 2005.

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

Other inspections for this house

Leigh Bank 11/08/06

Leigh Bank 25/01/06

Leigh Bank 05/01/05

Leigh Bank 07/07/04

Similar services:

Littledale Hall Therapeutic Community

Bennett House

Padgate House

Mary & Joseph

Westcliffe House

Richards House

Hamer Cottage

Turning Point (Hoole Road)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Leigh Bank Leigh Bank 4 Glebelands Road Prestwich Manchester M25 1NE Lead Inspector Lucy Burgess Unannounced Inspection 26th October 2005 10:00 Leigh Bank DS0000008455.V259796.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 Leigh Bank DS0000008455.V259796.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. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Leigh Bank Address Leigh Bank 4 Glebelands Road Prestwich Manchester M25 1NE 0161 773 1523 0161 773 0125 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) Turning Point Care Home 11 Category(ies) of Past or present alcohol dependence (11), Past or registration, with number present drug dependence (11) of places Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the maximum registered numbers there can be up to 11 people with past or present alcohol dependence and up to 11 people with past or present drug dependence. The service should employ a suitably qualified and experienced Manager who is registered by the Commission fot Social Care Inspection. 5th January 2005 2. Date of last inspection Brief Description of the Service: Leigh Bank is an 11-bedded residential care home for younger adults (18yrs – 65yrs) with problems associated to drug and alcohol misuse. At the time of the inspection only 9 people were resident at Leigh Bank. The property is situated in Prestwich, Manchester and is close to the M60 motorway network. It is convenient to local shops, leisure facilities and the metro tram network. The accommodation is an old Victorian style semi detached house in keeping with other properties within the area. The accommodation comprises of 7 single bedrooms and two double rooms. All services such as heating, lighting, food, accommodation, staffing costs and laundry facilities are included as part of the fees. A large well maintained garden is available to the rear of the property. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day for a period of 6 ½ hours. The inspector took the opportunity to look round the home, view records as well as talk with a number of residents and staff. Discussion and feedback was also held with the Manager. The home is registered to provide accommodation for 11 people. There were 9 residents at the home at the time of the inspection. What the service does well: What has improved since the last inspection? A new team leader has recently been employed at Leigh Bank and has a vast amount of knowledge and experience in relation to addictions, group work, counselling and therapies and the needs of those undertaking rehabilitation. One staff member expressed that the new manager had already made a big improvement to the home and was enthusiastic about the development of the project. The homes managers have arranged for improvements to be carried out throughout the home, which will enhance the environment. Feedback received from residents was that they were very happy with their rooms and had enjoyed redecorating and personalising it to make it more homely and relaxing whilst they were staying there. The staff had supported and encouraged this. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Leigh Bank DS0000008455.V259796.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 Leigh Bank DS0000008455.V259796.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 The detailed assessment undertaken before admission gives an assurance both to residents and staff that individuals are only admitted if the home feels that needs can be met. EVIDENCE: Leigh Bank is a specialised service for those individuals wishing to recover from alcohol and drug misuse. The length of placement varies with funding provided on a 3, 6 or 12 monthly basis. This is kept under review. Residents are admitted following assessment by the funding authority and/or relevant professional who may be involved i.e.: Probation Officer, Mental Health Worker. Further assessment is also undertaken by staff at Leigh Bank prior to admission so that further information in relation to the support required can be sought. This information is then used to inform the development of a care plan. Individuals also have the opportunity to meet with other residents. The project has a clear criteria in relation to who is admitted to the home. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 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 to 10 Care plans are in place for each resident. Risk assessments do not fully reflect the support needed. These should be developed ensuring residents health and well being is maintained and risk is minimised. Residents feel able to approach staff and were seen to enjoy open and friendly relationships with staff. EVIDENCE: Care plans and risk assessments have been developed for each of the residents. Information includes details about their physical, emotional and mental health, medication, relationships, resettlement and finances. Goals had also been identified along with reviewing timescales. Each resident has an individual care plan, which is based on the initial assessment. Plans are developed together with the resident during the planned 1-2-1 sessions with their identified key workers. This enables residents to make decisions about their lives. Care plans had been agreed and signed by the resident. The project continues to provide information in relation to individual progress to the funding authority. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 Page 10 Turning Point has a risk assessment/management policy in place. As already stated assessments have been developed for each resident where a particular risk has been identified. Generally action to reduce/eliminate the risk had also been recorded providing staff with guidance when supporting individuals. One file seen did not fully assess all the concerns identified. This included an eating disorder and self-injurious behaviours. All areas of risk need to be fully assessed and management strategies developed in order to minimise the risk of keeping individuals safe from harm. Further signed documentation is also held in relation to consent to information being shared, behavioural policy/agreement, self-medication, and confidentiality and licence agreement. Information is held securely within the staff office and easily accessible to staff. Additional records are completed in relation to daily reports. These outline what residents have done throughout the day. Records would also be used for monitoring purposes should changes in health or behaviour be noted. Placement at the project varies in relation to the length of time. As the project provides rehabilitation support individual needs change as the programme of recovery is worked through. The home is strict in relation to breaching the homes ‘rules’. Any breaches would result in notices being issued with a time frame for improvement or termination, this ensures that other residents are protected. All incidents are documented and placed on file. Issues would then be discussed within the 1-2-1 sessions. As the home is relatively small, informal day-to-day contact is made between residents and staff with the views and opinions of both parties being easily aired. This method is used as well as formal meeting and discussions. Feedback received from the residents was positive and that they were happy with the support provided. Interactions with staff were seen to be open and friendly. Residents felt they could speak to members of the team in confidence. Residents would seek out additional support if needed. Comments received included, “they provide good support and advice’, ‘we’re encouraged to move on and try new things’, ‘they don’t judge me’ and ‘ I feel I’ve got another chance’. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 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 to 17 The structure and routine within the home is such that residents and staff are able to address individual needs as well as develop their confidence and abilities so they feel able to positively move on from rehab. EVIDENCE: As part of the structured programme at Leigh Bank residents are required to attend structured group work sessions. Additional support and encouragement is offered as well for individuals to maintain or develop their practical skills and pursuing other interests. Residents’ needs are identified and support is offered during the group work sessions as well as the 1-2-1 sessions held with their key worker. The new manager is to explore further leaning opportunities and develop the group work offering additional learning and development opportunities. Routines around the formal group work sessions are flexible and are dependant on individual preferences. Where restrictions are in place these are stipulated in the licence agreement. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 Page 12 The staff will provide support to residents when accessing services and As there is a facilities within the surrounding and wider community. commitment to completing the programme and due to the placement funding arrangements residents are unable to undertake full time employment, however they encouraged to pursue other options in order to increase their employment prospects and practical skills. Opportunities have been explored with ‘progress to work’ for training to be carried out at the home. The agency provides training courses in computers, community care work etc. Some individuals also access the local colleges. A number of activities are undertaken both in and away from the home. These include quizzes, playing music and DVD’s, visiting the library, playing pool and shopping. Community resources are accessed by local transport. Owing to the placement at the project being short stay, none of the residents receive the electoral vote at this address. As part of the day to day running of the home residents are also actively involved in carrying out household tasks including cleaning, washing, cooking and shopping. Residents hold weekly meetings and nominate a ‘resident rep’, specific tasks are then shared out during the meetings. The ‘resident rep’ will also attend the staff meetings to share information/ideas etc. Shopping and menus for the evening meals are planned, agreed and cooked by the residents. Information is recorded. Individual arrangements are made for breakfast and lunch. A healthy balanced diet is encouraged and menus are recorded. Residents are able to access the kitchen and food/snacks throughout the day. This was observed during the inspection. As some of the residents are from the local area opportunities are available for them to visit family members enabling them to maintain their relationships. During the visit one of the resident went off to spend some time with his family. Visits also take place at the home and residents may see them in private. Arrangements can also be made for visitors to stay over night as part of the rehabilitation process. A risk assessment would be completed. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 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, 19 and 20 Relationships with health care professionals are effective and provide positive support networks for the residents ensuring their health needs are promoted. The medication system needs to be improved to reflect the safe practice ensuring residents are protected. EVIDENCE: In relation to the health care needs of residents individuals have access to a local GP as well as other health care professionals when necessary. The GP known to the home is unable to take any further patients therefore alternative arrangements are to be made ensuring the health needs of residents continue to be met. The team leader is to meet with the new GP to discuss the general needs of residents who receive support at Leigh Bank and how they can assist as part of the rehabilitation programme. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 Page 14 Where individuals have additional needs such as mental health needs, psychiatric services would be accessed to offer further support and advice. This information would be detailed on the initial assessments and the care plan. Residents living at Leigh Bank are able to manage their own personal care needs and facilities are provided on each floor, therefore easily accessible. Encouragement is provided where necessary. The current medication system was found to be inadequate. The medication system used had previously been supplied by BOOTS, however this had recently changed. Whilst viewing two of the bedrooms medication was found to have been left on the bedside table in one residents’ room and in another had been stored in the locked cabinet however the keys had been left in the lock and the bedroom door was unlocked. More suitable arrangements need to be explored ensuring the system is safe. Self-medication risk assessments are completed for each resident on their admission. Documents are signed and dated and held on individual files. These too need to be expanded upon. The manager is aware that the current system is inefficient and alternative arrangements are to be discussed and implemented with the Service Manager. Several members of the team have completed the basic medication training. The Service Manager expressed that all staff will be offered training up to the advanced level providing them with the with clear knowledge and understanding in relation to the medication prescribed for residents. Leigh Bank DS0000008455.V259796.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 and 23 Satisfactory arrangements are in place in relation to the protection of service users as well as responding to their concerns. However training is outstanding in this area ensuring residents are protected. EVIDENCE: The home has in place a complaints procedure outlining what action will be taken to respond to any complaints. Copies of the documents have been included within the Residents handbook (service user guide). Copies are handed out to all new residents. Any issues raised would be recorded outlining action taken. No complaints have been raised at the home or with the CSCI. The home has a copy of the Local Authorities Adult Protection procedure as well as an in-house procedure. Outstanding training for some members of the team is still needed ensuring the safety and protection of residents. The home also has a behavioural policy, which is issued to residents when arriving at the home. Residents are asked to sign the policy to evidence they have read and understood the document and a copy is held on file. Other policies are in place for the protection of the service users, these include; incident reporting, violence and aggression, missing persons and risk management. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 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 and 30 Leigh Bank provides a comfortable homely environment for those that live there. Further redecoration and refurbishment is to take place, this will further enhance the home. EVIDENCE: Leigh Bank is a residential care home providing support for up to 11 younger adults with problems associated to drug and alcohol misuse. At the time of the inspection 9 people were resident at the home. The house provides accommodation on 3 floors. There are seven single bedrooms and two shared rooms. None of the bedrooms in the main house have en-suite facilities. One of the single rooms is situated to the rear of the property in a small annex. This is known as ‘the lodge’ and includes a shower room and kitchenette. Communal facilities include a large lounge, kitchen/diner and smaller lounge, there are also several bath/shower rooms and toilets. A basement room accommodates gym equipment, which is used by the residents. The home also has well maintained gardens to the front and rear of the property. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 Page 17 The home is spacious and comfortable. Several areas where seen to require attention, these included the redecoration of bedrooms and the vents in each of the bath/shower rooms need cleaning. The manager expressed that a surveyor would be visiting to look at the home and assess if any further work was required, this would then be considered within the organisational budget/plan. Work has already take place with the repainting of the hall, stairs and landing. Measurements have also been taken so that all bedrooms can be fitted with new carpets. A further television is being purchased for the smaller lounge enabling residents to have a choice of what to watch. It is advised that the manager develops a redecoration/refurbishment plan identifying the work required and timescales for action. A copy of the plan should be forwarded to the CSCI. It was also noted that one of the residents had recently decorated her room herself with the help of other residents. She had also purchased new furniture items. The resident expressed that she wanted the room ‘to be homely for the time she was spending there’. Great care and attention had been made providing a comfortable room. Other rooms seen had also be personalised by individual residents with pictures and belongings. This is to be encouraged providing individuals with a comfortable and familiar environment whilst working through the programme. Individuals are provided with keys to their rooms and a lockable space for the safe storage of personal items and medication. Spare keys are kept in the office. With regards to domestic tasks the residents carry these out. A resident meeting is held each Monday and is chaired by the resident’s rep. Agreements are made as to who is responsible for specific tasks within the communal areas. The home was found to be generally clean and tidy. Leigh Bank DS0000008455.V259796.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): 32, 33 and 35 Staff at the home are in sufficient numbers to meet the needs of residents. Training has been provided to equip staff with the knowledge and skills needed in meeting the needs of residents. EVIDENCE: The staff at Leigh Bank consists of the team leader, 3 project workers, a resettlement worker and administrator. Cover is provided each weekday from 9am through to 10pm and weekends between 9am and 5pm. Generally this will comprise of double cover between the hours of 9am and 5pm, then single cover at evenings and weekends. An on-call service is also available. On the day of the inspection there were 9 residents placed at the project. Sufficient staff were on duty for the current levels of occupancy. No new staff, other than the Team Leader have been employed at the home. Information and references regarding the team Leader will be sought as part of the Registered Manager application process. At present each of the staff files are being reorganised ensuring all necessary information is held on file. Recruitment practices and documentation will be examined further at the next inspection visit. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 Page 19 Each of the project workers and resettlement officer have yet to commence the NVQ level 3 training, however arrangements have been made for this to commence. The new manager is also a qualified NVQ assessor. Recent training has been provided for some of the staff, this has included Workshops in relation to stimulants and how they affect you, 1st aid and medication training. Further training in relation to medication and vulnerable adults needs to be provided for those who have yet to undertake the courses. One staff member is also to complete a management of health and safety course as her role includes ensuring the health and safety of the home environment is maintained. Further reading is also being done by staff in relation to Neuro Linguistic Programming (NLP) training. This is used as part of the group work and looks at how individuals learn about control, taking responsibility and values etc. Leigh Bank DS0000008455.V259796.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): 38 and 39 A clear management structure is in place providing both residents and staff with the support needed as well as developing the service ensuring the needs of the residents. EVIDENCE: Turning Point has recently appointed a new Team Leader. A Registered Manager application is to be submitted to the CSCI for processing. The Team Leader has a wealth of experience and qualifications. These include facilitating training sessions, counselling and therapy groups. With previous employment within the prison setting. He also has a lot of knowledge and skills in relation to understanding addictions, stress management and behavioural therapies. The manager is supported by the service manager who is available at the home for some time during each week. Both managers appear to have a good rapport and are committed to developing a quality service, which meets the needs of the residents. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 Page 21 One member of the team felt that the change in management has made an improvement to the overall running of the home. Following the inspection the Service Manager was to give an overview to residents and staff of the proposed legislation with regards to rehabilitation services. All the residents had agreed to attend and their feedback/comments would be requested. In relation to the day to day running of the home decisions are clearly made with the involvement of the residents. Information is shared and residents are encouraged to make decision and share ideas. Leigh Bank DS0000008455.V259796.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 3 X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Leigh Bank Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X 2 3 X X X X DS0000008455.V259796.R01.S.doc Version 5.0 Page 23 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 YA9 Regulation 12 Requirement That risk assessments are expanded upon to include areas of concern identified within the assessment. That the system of medication is reviewed ensuring practice is safe. That all staff receive training in relation to Vulnerable Adults. That the ventilation fans in each of the bathrooms are cleaned. That training is provided as identified within the report. Timescale for action 30/12/05 2. 3. 4. 5. YA20 YA23 YA30 YA35 13 18 13/23 18 30/12/05 30/01/06 30/12/05 30/01/06 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. 2. Refer to Standard YA24 YA38 Good Practice Recommendations That a copy of the redecoration/refurbishment plan is forwarded to the CSCI. That the Registered Managers application is forwarded to the CSCI. Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Leigh Bank DS0000008455.V259796.R01.S.doc Version 5.0 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!