CARE HOME ADULTS 18-65
Lister Project 2a Basegreen Road Sheffield South Yorkshire S12 3FH Lead Inspector
Mrs Janis Robinson Key Unannounced Inspection 7th September 2006 09:00 Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Lister Project Address 2a Basegreen Road Sheffield South Yorkshire S12 3FH 0114 249 0553 0114 249 0950 j.carr@syha.co.uk None South Yorkshire Housing Association 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) Joanne Helen Carr Care Home 25 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (25), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 25 MD mental disorder of which 9 can be used for people with an additional PD (physical disability) This registration includes 5 places at 95 Lister Avenue, Sheffield S12 3FQ; 7 places at 2A Basegreen Road, Sheffield, S12 3FH; 4 places at 2B Basegreen Road, Sheffield S12 3FH; 4 places at 2C Basegreen Road, Sheffield S12 3FH; & 5 places at 2D Basegreen Road, Sheffield S12 3FH Four specific service users over the age of 65years named on variation 15.08.05, may reside at the home 7th March 2006 3. Date of last inspection Brief Description of the Service: The Lister Project provides personal care and accommodation for up to twenty five service users who have mental health problems. The project consists of five adjacent houses, each accommodating up to five service users. An external pathway links the houses. To the rear of the houses is an enclosed communal garden, which is provided with seating. Each of the houses is provided with a communal lounge, dining room, kitchen, showers and bathrooms. All of the bedrooms are single. A central kitchen provides the main meals for each house. The home is based in a residential area of Sheffield close to shops and public transport. South Yorkshire Housing Association owns the home. The fees are £265.00 per week. A statement of purpose and service user guide are available to prospective and current service users and their representatives. Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced. A site visit took place over 7 hours from 9.00am to 4:00 pm. An inspection of a proportion of the environment was undertaken. A proportion of records were checked, including care plans, menu, rotas, medication, recruitment and staff training. Interactions between Residential Mental Health Workers (RMHW) and service users were observed, and the inspector joined a house meeting between service users and RMHWs. Ten service users were spoken with, individually or in small groups. A proportion of the staff on duty were spoken with, including housekeeping, domestic, cook, RMHWs and a deputy. Two RMHWs were interviewed. At the time of this inspection the homes permanent manager was on maternity leave. Discussions took place with the temporary manager. What the service does well:
All of the staff spoken with displayed a commitment to the service, and to supporting service users. Staff and service users were positive about the temporary manager, and felt that the handover had been managed smoothly and well. The interactions observed between service users and staff appeared respectful and supportive. Service users said `The staff are sound’, ‘The staff give you what support you need’, and `I can talk to my key worker’. Support plans were in place for all service users. These set out in detail the personal, social and health care needs of the individual, and the staff action required to ensure these needs were met. Service users were supported to take risks and make decisions about their lives. A policy on confidentiality was in place; to ensure residents rights were respected. Access to day care facilities was available to those service users who wished to access these. RMHWs supported activities and trips out of the home. There was an open visiting policy, to encourage contact with relatives and friends. The routines at the home were flexible, to enable service users to have some control over their lives. The menu was varied, and individual preferences were respected. Service users health care was monitored and access to relevant professionals was available to ensure health was maintained. Medication was stored securely. Staff that administered medication had been trained to do so safely. On the day of the inspection the environment was clean. Communal areas contained homely touches to create a comfortable environment. A rolling programme of redecoration was in place. Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were kept. There was a quality
Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 6 assurance system, which sought the views of service users and their representatives. Records within the home were stored securely, to respect confidentiality. Health and safety procedures were identified and carried out, and systems were checked and serviced to maintain a safe environment. Staff undertook mandatory training to ensure their skills were maintained. What has improved since the last inspection? What they could do better:
Priority must be given to ensuring the risks of fire are minimised. The fire alarm must be updated to a more efficient system. Extractor fans must be provided in smoking areas to improve the environment for non-smokers. Whilst staff were being provided with mental health awareness training, skills would be further improved with the provision of specialist training related to specific mental health conditions. Training in sanctions and restraint had not been provided to staff. The inspector acknowledges that improved systems to audit medication had been identified. These need to be put in place to ensure safe procedures are followed. An audit by the homes pharmacist needed to take place, in line with the projects policies. Some service users told the inspector that insufficient crockery and cutlery were available. Three kitchen work surfaces were badly marked and in need of replacement.
Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 7 Whilst staff recruitment files contained the majority of the required information to evidence that safe procedures had been followed, one file did not contain proof of identity and a further file contained gaps in employment history that had not been explained. 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. Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 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 Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs had been assessed prior to admission, to ensure the home could meet their needs. EVIDENCE: Three service users support plans were examined. Each contained copies of assessments undertaken prior to admission. The assessments were comprehensive, and contained information obtained from other relevant professionals, such as psychiatrists and social workers. Sufficient information had been obtained to enable an informed decision regarding the suitability of the placement. Information gathered from assessments was reflected in individual support plans. Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user had a support plan, to ensure his or her opinions had been sought and needs assessed. Service users were supported to make decisions to ensure they had some control of their life. Service users were supported to take risks to ensure they led full lives as safely as possible. There was a policy on confidentiality, to protect service users rights. EVIDENCE: Three support plans were examined. These were well set out and easy to read. Where they had chosen to do so, service users had signed the plans to evidence that they had been involved in its drawing up. Plans contained a statement confirming that individuals had access to their plan as they wished. The plans contained a comprehensive range of information covering all aspects of personal, health and social care. The plans identified the staff action required to ensure identified needs were met. Risk assessments were in place, to ensure that all identified risks were well managed whilst providing some independence to service users.
Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 11 Service users were able to make decisions about their lives. Service users were observed making choices about where and how to spend their time, and staff respected these decisions. The policy on confidentiality in place ensured information about residents was kept safe. Service users said they liked living at the home; the staff were ‘sound’ and ‘gave all the help they could’. They said that they had everything they needed. Service users confirmed that they could make decisions, and the routines at the home were flexible. The ethos of this project was to support and empower service users. This was reflected and echoed in support plans and discussions with all staff. Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had opportunities to participate in some activities to enrich their lives. Some service users independently accessed facilities in the local community. Staff supported other service users to access these facilities if required. Trips out of the home were organised for service users to enjoy leisure time. Contact with families and friends were maintained to support service users. Service users rights were promoted and responsibilities were identified. A varied diet was provided and preferences respected to maintain health and well-being. EVIDENCE: A range of activities was offered to service users, which included trips out of the home to local shops, clubs and pubs. Attempts to improve the range of activities provided had been successful. The homes rota had been adjusted to create additional staff on identified days to facilitate activities. A dedicated activities worker had been employed and at the time of this inspection was working with four service users on an individual basis. Staff continued to
Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 13 motivate service users. A winter ball had taken place last year for service users and staff, that service users were involved in organising. At a house meeting held on the day of the inspection, staff and service users decided to plan a further winter ball for later in the year. Service users had also identified trips out, such as short breaks to the coast, which had been facilitated. Staff confirmed that contact with service users families and friends were maintained. The home had an open visiting policy to encourage contact. One service user told the inspector that their daughter and grandaughter visited them regularly. Another service user said her boyfriend regularly visited and stayed for meals. A central kitchen provided the main meals to service users in their houses. This had been reviewed and in response to service users preferences, the main meal was no longer going to be provided at lunch time, but would be provided in the evenings. Breakfast and snacks were available within each house. Service users said that they enjoyed the food. One service user said that they could have what they wanted. The record of food provided was varied and appeared healthy. Alternatives to the menu were always available. Service users were involved in menu planning, food shopping and meal preparation, to develop and support their independence. Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users personal support needs were assessed and met. Staff monitored service users physical and emotional health, to ensure this was maintained. Medication systems had been audited and improvements identified. Medication was stored securely and administration records were up to date, for service users protection. Service users needs regarding long-term care and death were identified to ensure these would be carried out. EVIDENCE: Support plans contained information on service users personal care needs in detail. The plans set out the staff action required to ensure all identified needs were carried out. The support plan recordings were specific and comprehensive. Staff had a clear understanding of the individual needs of service users, and the knowledge to ensure personal care needs were met respectfully. The majority of service users were able to independently meet their personal care needs, plans contained information on encouragement and advice. Support plans contained information on all aspects of health care. Appointments and treatments with health care professionals were recorded to
Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 15 ensure these were monitored and health was maintained. The plans evidenced that service users emotional health was monitored and any concerns identified were referred to relevant specialists. Access to health care professionals was available. Staff responded to any health concerns promptly. An internal audit on medication systems had been undertaken. An improved system of monitoring had been identified. This was being put in place to ensure all risks were minimised. Contact with the pharmacist was maintained, and an audit by the pharmacist had been requested, in line with written procedures. Medication was stored securely. Support plans included assessments to self-administer, and consent to medication to evidence that safe and informed practices were carried out. The medication administration records examined were accurate, fully recorded and up to date. Support plans contained information relating to long-term illness and dying. The wishes of service users had been sought from them or their representatives, to ensure any specific wishes were carried out. Staff displayed a strong sense of commitment to the service users living at the home. Positive and caring interactions were observed between service users and staff. Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints procedure was in place, to ensure any concerns were listened o and taken seriously. An Adult Protection procedure was in place, to ensure service users safety was promoted. EVIDENCE: A written complaints procedure was in place. Service users had been provided with a leaflet informing them how to complain, should they wish. It contained contact details of the local office of the Commission for Social care Inspection. All of the service users said that they would tell their key worker, or other staff, if they had any concerns. No complaints had been received by the home. There was an Adult Protection policy in place, which included the Department of Health guidance `No Secrets’ to ensure staff had access to all of the information needed to promote residents safety and well being. The organisation had a procedure to provide staff training in adult protection on an annual basis to equip them with the skills and knowledge needed to ensure service users were safe, and to respond to any allegations appropriately. Whilst policies and procedures were in place regarding physical and verbal aggression, staff were not provided with formal training on sanctions or restraints, to ensure they were aware of safe and acceptable practice in line with the ethos of the home.
Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 17 Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and well maintained. Homely touches had been provided to create a comfortable environment. Further provision and refurbishment was required to ensure the environment was as free of risk as possible, in relation to smoking. A rolling programme of redecoration and refurbishment was in place. EVIDENCE: A proportion of the building had been refurbished and redecorated. New sofas, dryers and furnishings had been provided since the last inspection. Communal lounges and dining rooms were provided with homely touches to create a comfortable environment. All of the service users said the home was comfortable and they were happy with their rooms. However, some furniture was worn or showed signs of age. Some furniture was marked and damaged from discarded cigarettes. Some kitchen work surfaces were marked and worn. This did not contribute to the overall comfort of the environment. Due to the complex needs of some service users, damage to the environment constantly took place. This must be reflected within the homes maintenance
Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 19 budget, and sufficient funds made available to ensure a comfortable and wellmaintained environment is provided. Several service users were heavy smokers, and as a consequence, some rooms were very polluted with smoke. Whilst the non-smoking service users said that this did not bother them, extractor fans must be provided for the safety and comfort of service users and staff. Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Agreed levels of staff were being maintained. Good relationships between staff and service users were observed. Some staff undertook NVQ training to improve their skills. Recommended levels of NVQ trained staff were being achieved. A thorough recruitment procedure was in operation, to protect service users. Some staff files had gaps in information. Staff undertook periodic training to keep them up to date and equip them with the skills needed to carry out their duties. A staff training plan and individual training records were maintained. Staff supervision, to develop and support staff, took place at the required frequency. EVIDENCE: The staff had a positive attitude to their jobs and displayed high level of commitment to the service users. Friendly and supportive relationships were observed between staff and service users. The homes rota indicated that agreed levels of staff were being maintained. All of the staff reported a good team spirit at the home. Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 21 Three staff recruitment files were checked. They contained the majority of information required. Criminal Records Bureau (CRB) checks had been undertaken on all staff. One file checked contained gaps in employment history that had not been explored. A further file did not contain proof of identity. Staff undertook periodic training relevant to their job. Six of the staff team had undertaken the training in mental health awareness, this training was being provided to all Residential Mental Health Workers, to ensure they were equipped with an understanding of the complex needs of service users, and to provide them with essential skills that reflect the specialist nature of the home. Some staff said that they would further benefit from training on special conditions related to mental health, such as schizophrenia. A training plan and individual training records were maintained to ensure effective monitoring took place. Of the 16 care staff, 12 staff had achieved NVQ level 2 or 3 in care. All staff reported that they had regular supervision, to ensure they received sufficient support and guidance. Records inspected evidenced that staff supervision took place at the required frequency. Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was well run. Management were approachable and supportive to staff and service users. A quality assurance system was in operation, to monitor the service. Health and safety systems were in place, to protect service users and staff. The fire alarm required updating. EVIDENCE: A temporary manager was in post covering maternity leave. Service users and staff benefited from the managements leadership style. Staff said that the manager was approachable and supportive. A quality assurance system was in operation, to monitor the service and obtain the views of service users and their representatives. However, the last service user and representative survey was dated 2004. Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 23 Health and safety systems were checked and serviced. Mandatory training had taken place and systems were in operation to ensure staff were provided with refresher training when needed. Fire training was provided to staff over and above the required frequency, in recognition of the fact that the majority of service users smoke, and some discard their cigarettes in a way that is potentially unsafe. A fire inspection took place on 26/06/06. The fire alarm system at the home did not indicate the specific location of a fire. The fire officer recommended that the system be updated to use sprinklers. A site meeting had been arranged for 26/09/06 for the fire officer and property services officer to discuss the most appropriate system for the home. Timescales for installation would then be agreed. This has been confirmed in writing to the CSCI. Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 2 X X 2 X Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 25 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 YA23 Regulation 13 Requirement Timescale for action 31/12/06 2 YA24 23 All staff must be provided with sanctions and restraint training. (Previous timescale of 01/06/06 not met) 31/12/06 All areas of the home must be well maintained and decorated. Marked kitchen work surfaces, and cigarette-damaged furniture, must be identified for replacement within the homes maintenance programme. Sufficient cutlery and crockery must be provided. Sufficient budget, that reflects the heavy wear on furnishings, must be provided to ensure a clean, comfortable and safe environment is constantly maintained. 3 YA24 YA42 23 All necessary precautions to reduce the risk of fire must be undertaken. The fire alarm system must be updated to provide a more efficient means of detecting fire. (Previous timescales of 01/06/06 31/12/06 Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 26 not met) 4 YA24 23 Extractor fans must be provided in communal smoking areas. (Previous timescale of 01/07/06 not met) Recruitment files must contain proof of identity. All gaps in employment history must be explored. All staff must be provided with training on conditions related to mental health. The quality assurance system must include obtaining the views of service users and their representatives. A quality assurance survey must be undertaken. 30/11/06 5 6 7 8 YA34 YA34 YA35 YA39 18 18 18 12 30/11/06 01/12/06 31/01/07 31/01/07 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 YA37 YA20 Good Practice Recommendations The registered manager must achieve NVQ level 4 in management by 2005. The identified improvements to the monitoring of medication systems should be put in place. Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Lister Project DS0000002981.V308693.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!
