Inspection on 13/09/05 for Lindley Cottage

This inspection was carried out on 13th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lindley Cottage 13/06/07

Lindley Cottage 26/06/06

Lindley Cottage 11/01/06

Lindley Cottage 05/01/05

Lindley Cottage 12/08/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Lindley Cottage 6 Lidgett Street Lindley Huddersfield West Yorkshire HD3 3JB Lead Inspector Alison McCabe Unannounced Inspection 13th and 29th September 2005 2:25pm Lindley Cottage DS0000001117.V250852.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 Lindley Cottage DS0000001117.V250852.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. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lindley Cottage Address 6 Lidgett Street Lindley Huddersfield West Yorkshire HD3 3JB 01484 645169 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) St Anne`s Community Services Miss Helen Sykes Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2005 Brief Description of the Service: Lindley Cottage offers nursing care and accommodation for five adults with learning disabilities. St Anne’s Community Services operate the home. Lindley Cottage is a former family residence backing onto the Lindley recreation ground. It is located within Lindley village close to local amenities. There is a large garden to the rear of the property for service users’ use. There is limited parking to the front of the building. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted by one inspector over two days. Due to the nature of some of the concerns identified on the first day of inspection, a further visit was conducted with the service manager of the home. The inspection was conducted between the hours of 2.25 pm and 7 pm, and 10 am and 12.55 pm. As part of this inspection, a tour of the premises was conducted, care records examined and discussion with the manager, deputy manager and service manager took place. Due to their complex needs, discussion between the inspector and service users was limited. A number of serious concerns regarding the management of some behaviour exhibited by some service users were identified during this inspection. The CSCI will conduct further visits to the home in order to monitor progress with requirements made. The findings of the inspection are not positive, however it must be noted that, due to some of the issues that arose during the inspection, the range of standards assessed was limited. There may, therefore, be a number of standards that the home has achieved that were not assessed on this occasion. It must also be noted that the service manager has acknowledged the difficulties and has demonstrated his commitment to resolving the areas of concern that have been identified. At the second visit, as part of this inspection, the service manager reported that he had made arrangements for a specialist consultant to come into the home to work with the staff team around the behavioural issues, and an acting manager from another home had been moved to Lindley Cottage in order to support the staff in improving the service. What the service does well: What has improved since the last inspection? The lounge has been re-carpeted and pictures and ornaments have been purchased to make the room more homely in appearance. The window in the upstairs toilet has been repaired. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 6 The seal around the cooker has been replaced. A service user’s bedroom has been redecorated. The freezer has been moved from the laundry area. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Service users’ needs are assessed, however the information is not always used to ensure that service users ‘needs are met appropriately. Not all service users are having their needs met at this home. EVIDENCE: Since the last inspection a new service user has been admitted to the home. The social worker and community nurse completed a pre-admission assessment with input from the service manager. The manager of Lindley Cottage stated that she had no involvement in this process. There was no evidence that the pre-admission assessment information had been used to develop an individual service user plan, nor that potential restrictions on choice or freedom of movement had been agreed and discussed during the assessment process. The care plan had been transferred from the service user’s previous placement and had not been updated to reflect the change in service. The manager said the staff team had recently updated written behavioural guidelines, however these were still in draft format at the time of inspection. The inspector was very concerned that the service user had a number of restrictions placed upon him, and that physical intervention and seclusion were being used with this service user without there being any agreements or written guidelines/strategies. This is unsafe practice, has legal implications and must be addressed as a matter of urgency. The manager is advised to familiarise herself with the guidance from the Department of Health regarding physical intervention and people with learning disabilities. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 10 The inspector was not satisfied that the needs of the most recently admitted service user were being met. The service offered is not demonstrably based on current good practice nor was there any evidence that specialist clinical guidance had been implemented. Not all staff have the skills and experience to deliver the service the home offers to provide. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9 Individual care plans and risk assessments do not address service users’ needs and must to be reviewed. EVIDENCE: The home manager conducts a monthly audit of all service user plans, accident/incident records and goals. This is a useful exercise as it gives an overall summary of outcomes for service users. The reports of these audits were inspected and it was noted that service users often do not achieve their goals. For example: going horse riding and getting photos for communication purposes. The manager reported that staffing shortages have had an impact upon service users’ care plans being implemented consistently, along with the increased pressures on staff to manage behavioural issues at the home since the admittance of a new service user in March 2005. Two service user individual care plans were examined. It was noted that information gathered in a service user’s ‘Essential Lifestyle Plan (ELP)’ in August 2004 had not been used to inform the care plan. For example, the ELP states that the service user must not have the bedroom door shut, however this is happening on occasions when the service user is secluded as a result of challenging behaviour. There was no evidence that assessment information, Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 12 advice and recommendations provided by specialists for a service user had been used to inform the care plan. A service user’s care plan had not been updated when he moved to Lindley Cottage; the care plan developed at his previous placement had been transferred. Behavioural guidelines were in place for a service user giving staff guidance about how to manage incidents of challenging behaviour. Some of the guidelines seemed punishing and negative; the manager was unable to explain the rationale behind some of the guidelines. It is recommended that these be reviewed in line with standard 6.5; ‘The plan establishes individualised procedures for service users likely to be aggressive or cause harm or self harm, focusing on positive behaviours, ability and willingness’. Physical intervention is implemented on a regular basis at the home. Guidelines were not written in line with Department of Health guidance and the records of physical intervention were incomplete. Seclusion is used with two service users, however records of this were poor. There was no written evidence of agreements regarding restrictions placed upon service users. It is a requirement of the inspection that care plans be reviewed involving the service users, their families or advocates as appropriate and relevant specialists. Further discussion between St Anne’s and the CSCI will take place regarding the practice of seclusion. Risk assessments did not address all identified risks and must be reviewed alongside the individual care plans. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 16, Some service users have access to daytime occupation whilst some service users have limited opportunities to take part in valued or fulfilling activities, education or training. The routines and practice implemented at this home do not promote freedom of movement and individual choice. Service users’ rights are not always recognised and upheld. EVIDENCE: Of five service users living at Lindley Cottage, two have regular day care/education outside of the home. One service user receives two full days per week and one service user receives four hours per week. Staff at the home are responsible for the occupation of those service users without day provision. Difficulties in staff recruitment and retention have impacted upon the frequency and variety of activities that are offered to service users. On the day of inspection some of the service users had been supported to go to a butterfly farm in the morning. The manager and staff explained that some service users require one to one or two to one staffing ratios outside of the home, and this reduces the opportunities that are available as there are only three staff members on duty at any one time. The inspector observed that, Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 14 when service users were in the house, there was a lack of positive engagement in meaningful activities. Staff need to explore how they can support service users to be engaged in meaningful, age appropriate activities whilst they are in the house. It is acknowledged that a significant amount of staff time is taken up with dealing with certain behaviours that are displayed. A number of restrictions are placed upon service users at this home due to the nature of some behaviour displayed. There was no evidence that these had been agreed, and records in respect of restrictions were poor. The inspector was concerned to find that two service users are, at times, locked in their bedrooms against their will as a way of staff managing challenging behaviours. This is discussed in further detail under standard 23, protection. View holes have been installed in bedrooms, the bathroom, sitting room and dining room doors. The manager reported that this was in case service users were secluded in these areas, to enable staff to monitor the situation. The inspector is not satisfied that positive interventions, de-escalation or diversion techniques are implemented as a means of managing and avoiding challenging behaviour. Service users’ wardrobes/cupboards were locked in those bedrooms that were seen. The inspector was not satisfied with the rationale given regarding this. There was no evidence that positive, less restrictive alternatives had been considered. For example, rather than providing a dirty washing basket to a service user who put dirty washing in their wardrobe, the wardrobe had been kept locked to prevent this from happening. The inspector observed several occasions where staff were interacting exclusively with each other rather than with service users. For example, staff were in the kitchen together to prepare the evening meal, and to clear up after the evening meal and service users were in the lounge and hallway unsupervised. The manager reported that this was the usual practice at the home. None of the service users have a key to their own room. The deputy manager explained that this is not appropriate given the nature of learning disabilities of the service users. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Service users do not always receive personal support in the way they prefer or require. EVIDENCE: Additional information needs to be included within individual care plans about how service users prefer to be supported with their personal care. It was difficult to establish from information given by the deputy manager and manager about how service users are supported in some areas of their personal care. It was noted that service users are not provided with toilet paper, towels or soap, and are dependent upon staff members offering assistance in this area. The manager reported that service users are not always offered the necessary support with this; this was observed at the time of inspection. Staff must ensure that service users are provided with personal care that ensures that their privacy, dignity and independence is maintained. Records examined did not clearly set out service users’ preferred routines, likes or dislikes. This is particularly important for service users who cannot easily communicate their needs. The manager reported that agency staff are used on a daily basis at the home and, although where possible the same staff are used, this is not always the case. In order to ensure that consistency and continuity of support is achieved, clear personal support plans must be developed. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are not always adequately protected from potential harm or abuse. Records in relation to physical intervention and seclusion must be improved and all staff must be given the necessary training in the management of challenging behaviours. EVIDENCE: A satisfactory adult protection procedure, including whistle blowing, is in place in addition to the Kirklees Vulnerable Adult procedures. A comprehensive physical intervention policy and procedure is available that is in line with Department of Health guidance. It was noted however that practice in respect of physical intervention does not reflect the policy and procedure. Physical intervention and seclusion is used at this home. Records in respect of this practice were unsatisfactory. Insufficient detail was recorded on physical intervention records. It is concerning that some of the staff using physical intervention techniques have not had the appropriate training and that some of the techniques recorded as used are inappropriate and not in line with the training that has been received. Seclusion is being used in circumstances other than in emergencies as described in the Department of Health Guidance. Guidance for staff about when to use physical intervention or seclusion were either not available or unclear. The inspector was concerned that this does not adequately protect the service users from possible harm. Aggression by service users is not always understood and is not always dealt with appropriately. The deputy manager explained that attempts are being made to establish the possible causes of a service user’s behaviour. The service manager explained that St Anne’s has reviewed the physical intervention training that is delivered to staff and has made arrangements for Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 17 staff to receive training that is accredited by the British Institute of Learning Disabilities. This is a positive step, however in the interim the provider must make suitable arrangements to ensure that service users are protected. The service manager has arranged for a specialist consultant to work with the staff team in respect of managing and understanding individual service users’ behaviours. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Service users live in a clean home and each have their own bedroom. The registered person needs to explore how service users can be appropriately supervised without the need for obtrusive restrictions and measures. EVIDENCE: All recommendations made at the last inspection regarding the environment had been positively addressed. All areas of the home were seen. The home was clean and free from unpleasant odours with the exception of one service user’s bedroom. The deputy manager reported that laminate flooring had been ordered for this bedroom to improve hygiene. All service users have a single bedroom and these were individualised to reflect their interests. It was noted that service users’ wardrobes were locked. Any restrictions must be agreed with the service users or advocate/relative and a record made within the individual plan. The registered person should ensure that, wherever possible, restrictions placed upon service users to access their personal belongings are kept to a minimum and there is a clear rationale for such restrictions. These must be kept under review. Since the last inspection, efforts have been made to create a more homely environment in the lounge. Ornaments and pictures have been purchased and a new carpet fitted. The coffee table and sofa in the lounge need to be repaired or replaced as they are damaged. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 19 Two bedroom doors, the lounge, dining room and bathroom have been fitted with view holes. The manager explained that this was so that service users being secluded in these rooms could be observed. This raises issues about service users’ privacy and dignity and further discussion will take place between the provider and the CSCI regarding this matter. Toilet paper, soap and towels were not available on the first day of inspection. The manager explained that this is not left out due to behavioural issues with some service users. Toilet paper had been made available to service users when the inspector returned to complete the inspection, although soap and towels were not available without staff support. Such restrictions need to be agreed, recorded and reviewed regularly to ensure that any restrictions are based on current needs and risk assessments. The laundry is situated in the garage and the washing machine has a sluice cycle. The freezer has been moved from the garage since the last inspection. Infection control policies and procedures are in place and suitable arrangements have been made for the disposal of clinical waste. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33 The home needs to establish a stable, skilled staff team in sufficient numbers, in order to meet the needs of the service users. EVIDENCE: The manager reported that, since the admission of a new service user in March 2005, the home had gone through a difficult period of adjustment. Staff are often working in a reactive way in trying to manage challenging behaviours that are presented. This was observed at the time of inspection. It was reported by the manager that agency staff are used on most days to cover the rota, and this adds to the stress levels for both service users and staff. Staff need further training in autism and the management of challenging behaviour; particularly on how to anticipate and de-escalate potential incidents. Staff also need to be provided with up to date care plans and behaviour management guidelines to enable them to adopt a consistent approach when supporting service users and increase their understanding of behaviours displayed. There are currently vacancies for two full time and one part time care staff and one full time and one part time nursing staff. The manager said that a newly qualified nurse was due to start work at the home at the end of September. Additional hours have been allocated for one service user, however the manager said that they had been unable to recruit to these hours. In order to ensure that service users’ needs are met consistently and effectively, it is essential that a stable staff team be established. There is not always sufficient numbers of staff on duty with the necessary skills to meet the needs of the Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 21 service users; not all staff have received the required training in physical intervention techniques. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 41 Record keeping in respect of service users needs to improve. EVIDENCE: Service user records required by regulation were not all up to date. This has been discussed earlier in the report. Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 23 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 1 2 x x Standard No 22 23 Score x 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 x x 1 x Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 3 LIFESTYLES Standard No Score 11 x 12 1 13 x 14 x 15 x 16 1 17 Standard No 31 32 33 34 35 36 Score X 1 1 X X X CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lindley Cottage Score 1 x x x Standard No 37 38 39 40 41 42 43 Score X X X X 1 X x DS0000001117.V250852.R01.S.doc Version 5.0 Page 24 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 YA6 Regulation 15(2)b Requirement The registered person shall keep the service users plan under review. 31/3/05 unmet. The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the home. This was not assessed at this inspection. An up to date, comprehensive, person centred plan must be in place for all service users. This must include personal support needs, behaviour management plan including physical intervention plan, a record of any limitations agreed with the service user as to the service user’s freedom of choice, liberty of movement and power to make decisions. The registered person must ensure that seclusion is only used in an emergency situation as described in the Timescale for action 30/11/05 2 YA39 24(1)a,b 31/07/05 3 YA2YA6 YA16YA18 YA23YA41 12(1)a,15(1), Sch 3 30/11/05 4 YA6YA23 12(1)a,13 -6 7 8,37 20/10/05 Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 25 5 YA9 YA41 13(4) 6 YA16 YA24 12(3)(4)a, 13(6) 7 YA18 12(1)a,b,(4)a 8 YA23 YA41 13(6)(7)(8), 37 Department of Health guidance. There must be recorded evidence that all agreed behaviour management strategies have been tried in the first instance. This must be kept under regular review. Any incident of seclusion must be recorded in full and the CSCI notified. Detailed risk assessments must be in place for all service users that empowers individuals to participate in as many daily tasks and activities as possible. Risk assessments currently in place must be reviewed. The registered person must review the current arrangements in respect of view holes in doors, service users personal possessions being locked away, and communal areas being kept locked. Any such measures must be agreed and recorded and risk assessments must be in place regarding these practices. There must be a clear rationale for any restrictions and these must be kept under review so that restrictions can be reduced wherever possible. Service users must be supported to have their personal care needs met. Service users must have access, with support if necessary, to items required for their personal care, including toilet paper, hand soap and towels. Records relating to incidents of seclusion and physical intervention must be 30/11/05 30/11/05 20/10/05 20/10/05 Lindley Cottage DS0000001117.V250852.R01.S.doc Version 5.0 Page 26 9 YA23 YA32 10 YA33 completed in line with Department of Health guidance and the provider’s policies and procedures. Any such incidents must be notified to the CSCI. 13(6), All staff must be provided 30/11/05 18(1)(c)(i) with training specific to challenging behaviour, by an appropriately qualified trainer. All staff expected to physically intervene with service users must have undertaken a recognised and accredited course. This must be kept up to date, follow best practice guidelines and be specific to the needs of the individual service user. 12(1)b,18(1)a The registered person must 15/12/05 ensure that at all times suitably qualified, competent and experienced persons are working at the home in such numbers as are appropriate for the health and welfare of service users. Staff vacancies must be filled. 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 3 Refer to Standard YA2 YA3 A6 YA23 Good Practice Recommendations The assessment completed prior to service users moving into the home should be used to develop the individual care plan. The registered person should be able to demonstrate the homes capacity to meet the assessed needs of service users. Behaviour management plans currently in place should be reviewed to ensure they are current, clear and in line with current good practice guidelines. DS0000001117.V250852.R01.S.doc Version 5.0 Page 27 Lindley Cottage 4 YA12 The registered person should ensure that all service users are offered opportunities to participate in valued and fulfilling occupation in line with their assessed needs and individual care plan. 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