Inspection on 05/07/05 for Lorne House

This inspection was carried out on 5th July 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lorne House 29/11/06

Lorne House 20/01/06

Lorne House 07/02/05

Lorne House 12/07/04

Lorne House 09/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 LORNE HOUSE 14 Lorne Street Kidderminster Worcestershire DY10 1SY Lead Inspector Dianne Thompson Unannounced 5 July 2005 11:00 th 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 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 Stationary 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. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lorne House Address 14 Lorne Street Kidderminster Worcestershire DY10 1SY 01562 630522 01562 631074 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Gerardo Saporito and Mrs Brigida Saporito Mrs Gina Margaret Vaughan CRH 9 Learning disabilities 9 Category(ies) of LD registration, with number of places LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9 February 2005 Brief Description of the Service: Lorne House is a care home which provides personal care and accommodation for 9 adults with learning disabilities. Support is provided in a homely setting, enabling residents to lead as ordinary lives as possible. The home is located in a quiet residential area which is accessible to the centre of Kidderminster. Kidderminster rail station is a few minutes walk away. The premises consist of two adjoining terraced houses, which have been combined and adapted for their present purpose. All the homes bedrooms are single and have an en suite bath or shower facility. A garden at the rear is mainly used for growing vegetables and fruit. The house opens onto a terrace, which is a pleasant facility in good weather. The business is family owned. The owners live next door and are involved in the day to day running of the home on a full time basis. The owners are referred to in this report as the providers. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place on a weekday at 10.00 a.m. until 3.15 p.m. All 9 residents were out on a day trip to the nearby safari park. The inspector was given a tour of the home, which included all rooms, bedrooms and grounds to the home. Time was spent with the providers and the registered manager, all of who were open, helpful and co-operative throughout the inspection. The purpose of the inspection was to follow up on requirements and recommendations from previous inspections, and to monitor service provision within the home. What the service does well: What has improved since the last inspection? Since the last inspection there has been considerable effort to meet the requirements and recommendations from the last inspection. Although some remain outstanding, work is progressing in order to meet the required standards. Some examples of these improvements include amendments to the Statement of Purpose; medication controls and procedures now comply with the requirements; residents hold keys to their rooms where assessed as appropriate; induction and foundation training has been obtained through the local college, and other training opportunities explored. More detailed information in relation to further improvements since the last inspection are contained in the main body of this report. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 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. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 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 standard(s) 1, 2, 3, 4, 5 Information about the home is provided to all residents so that they can decide whether they would like to live at Lorne House and whether the home can meet their needs. A Statement of Purpose now contains the information required at the previous inspection, and a copy of this and the Service Users Guide is given to all residents. EVIDENCE: The home’s statement of purpose has been amended and now includes details of the manager’s qualification and experience, the size of rooms, and arrangements for protecting service users privacy and dignity. All information is being made available in symbol format, appropriate to the residents understanding and copies given to all residents. A resident has recently moved into Lorne House, and at the time of the inspection has lived at Lorne House for three weeks. There is evidence of planned, introductory visits and overnight stays, together with full, detailed assessments involving family, visits to the previous home, day care reports, and social worker input. Regular visits from family and the social worker are being maintained, and weekly psychology visits occur as part of the ongoing support arrangements. At the time of the inspection the new resident appears to be settling in well and has been spending time in the town, with staff support getting to know the area. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 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 standard(s) 6, 7, 10 The Care plans at the previous inspection did not meet the required standards, and although individual care plans are being developed they have not fully met the requirements. Residents hold their own care plans enabling them to be aware of the information they contain. Reviews, which have been conducted, indicate that choice and opportunities is offered. More comprehensive plans and more regular reviews would help support this further. EVIDENCE: There is evidence that care plans are being completed for all residents, but work is continuing to meet the regulatory requirements as set out in standards 6 and 2.3. Care plan reviews are inconsistent and should take place 6 monthly or more often if required. The manager considers that reviews are held regularly and that sometimes there were little or no changes to the care plan. When there are no changes to the service provided, care plans need to be signed and LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 Page 10 dated to indicate that they have been reviewed. Care plans are not always signed and dated by residents and/or their representatives. The recommendation that residents should hold care plans has been met. Considerable work has been completed with individual files to improve recording, and the detail of information contained in the file. The manager and inspector discussed ways of improving the recording system. The manager is planning to amalgamate existing separate files into two files – a working file and a main file. This will be completed for one resident and then trialled for a short period to enable feedback from residents and staff. Information in individual files rather than shared files will improve and maintain confidentiality and enable increased resident involvement in recording information in their files. It is suggested that a time limit be decided for the trial period of the new system, that the trial is evaluated, and a revised recording system be implemented as soon as possible. Documents have been seen in relation to the confidentiality of information. Records are kept securely and the staff are guided about confidentiality of information by the homes policy and procedure. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 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 standard(s) 12, 13, 14, 17 Residents have active and varied lifestyles and are supported by staff to take part in planned activities, holidays and day trips. The home is able to adapt to the needs of the residents, for example, providing day care facilities where needed and ensuring contact with families and friends. Residents are offered a varied and healthy diet, which includes home grown fruit and vegetables. EVIDENCE: Three residents attend local day services and two residents attend the local college. Residents take part in household activities– according to their individual preferences and abilities, such as setting table for meals, vegetable preparation, and cake making. Other regular activities encouraged and supported within the home include cooking, menu planning, shopping, and making sandwiches for lunch. There are activity plans in place for all residents and these are regularly updated. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 Page 12 The home is currently providing day services for the new resident during his settling in period. This includes familiarisation with Kidderminster and local amenities, as well as encouraging involvement in daily routines within the home. There is a Mini bus available for residents to use, and on the day of the inspection all residents were out for the day at the Bewdley Safari Park. Some residents attend an arts course at the local college, and evidence of their work is displayed in some bedrooms and on the walls in the home. Three residents regularly attend the Night out club; this is a club for people of Kidderminster with learning disabilities. It meets fortnightly and trips to pubs, clubs, and cinema are organised. The club supports involvement in the community and supports member’s contact with people they used to know, for example, from schools or day centres. There is evidence of a balanced, varied menu, which includes fresh fruit and vegetables. The home grows its own fruit and vegetables, which the residents sometimes help to harvest, although they are not too keen to cultivate the crops. The inspector saw the garden and the crops available. These included strawberries, cherries, runner beans and lettuce. Meals may be taken in the dining room or the kitchen. Barbeques in the garden are very popular with residents, and the patio area is well used in this and other ways. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 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 standard(s) 18, 19, 20 There are suitable arrangements within the home to make sure that resident’s health care needs are met. Since the previous inspection improvements have been made to medication procedures, which ensures and maintains the residents safety and security. EVIDENCE: It is evident that resident’s health needs are being met. There is access to medical services e.g. GP’s, Learning Disability Team and psychologist. Checks and visits to dentist, opticians are routinely organised and facilitated. A psychologist visits Lorne House on a weekly basis to support, advise and review service development within the home. Some case reviews currently involve input from other professional agencies, such as social workers and occupational therapists. The inspector and the manager discussed the implementation of Health Action Plan’s (HAP’s) as part of the care plan process. Staff have completed the training and are keen to implement this but due to the reorganisation of individual files this has not yet commenced. HAP’s are to be completed and incorporated into resident’s individual files as part of the review of the home’s recording system. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 Page 14 The previous inspection required the registered manager to ensure that: • • • • • Controlled medication is stored securely A record is maintained of all medication received into the home and that records show the reason for changes to medication. Medication Administration Records (MAR) are correctly compiled using coding key if medication not given. Medication records accurately show the dosage given when a variable dose is prescribed. Residents medication records show known allergies and state where ‘none known’. These requirements have all been met. The inspector requested that the recording be amended further to highlight allergies recorded on MAR sheets for ease of identification. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 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 standard(s) 22, 23 The complaints procedure has been amended and now makes it clear that CSCI (Commission for Social Care Inspection) can be approached at any time and complaints do not have to go via the home staff. The revised adult abuse and protection policy needs to be completed. EVIDENCE: The complaints procedure has been amended to indicate that complaints may be referred to the Commission for Social Care Inspection (CSCI) at any stage. A copy has been provided for CSCI. No complaints have been recorded or received in relation to Lorne House. Work to review the home’s Adult Protection Policy has commenced. The whistle blowing section, which includes an assurance that staff will not be disciplined or ostracised for divulging suspicions of abuse, has been completed and meets the recommendation of the previous inspection. This work was seen by the inspector and progress discussed with the manager. In the interim, information is available in a separate file to which staff have access. On completion the policy guidelines will be produced in symbol format, which is appropriate for residents understanding. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 29, 30 Lorne House is in a residential area of Kidderminster, within easy access to local community facilities and the town itself. The premises are suitable for their purpose of providing a home, which is safe, secure and comfortable for people with learning disabilities. EVIDENCE: The railway station is within easy walking distance. The home is in a three storey terraced house, with an enclosed garden to the rear. Originally two separate houses, they have been combined to form one fully integrated house. Three bedrooms are on the ground floor and are easily accessed by residents with mobility problems. The inspector was given a tour of the home, which included all rooms and residents bedrooms. A wall needs to be repainted in one of the bedrooms, which will maintain the overall appearance of the home. The home is clean and hygienic with no unpleasant odours. Sensors activate the lighting in all corridors. This is a requirement from the previous inspection, which has been met. A handrail needs to be fitted to one of the staircases, which will ensure the safety of residents and staff. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 Page 17 The bedrooms are homely, spacious, and individually decorated and furnished. All bedrooms have en-suite facilities. Notices are evident in all rooms written in signs and symbols appropriate for residents– e.g. evacuation procedures in the event of a fire. The previous requirement that residents hold keys to bedrooms, unless considered unsafe by risk assessment, has been met and is recorded on file. An aid-call system operates within the home and handsets are available in all residents and communal rooms. There are sufficient toilets and bathroom facilities on all floors, with separate laundry and kitchen facilities. The communal areas of the home are comfortable and well furnished, with adequate space for privacy or individual activities. The home keeps pets – an Alsatian dog, rabbits and a cat. Residents and staff provide for the care of the animals with appropriate hygiene arrangements in place. There are two conservatories, one leading on from the other. During the previous inspection the inspector was concerned that the area was cold and aggravated by the door needing to be open so the home’s dog could access the garden. An additional door has been fitted, with an automatic closure mechanism and the provider stated that heating to the second conservatory is planned. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35, 36 The needs of residents are being met through adequate levels of staff support. Regular training and staff supervision is provided to develop staff skills and knowledge in order to provide appropriate care and support to the residents. EVIDENCE: A staff rota showing all staff working within the home has been produced, as required in the previous inspection. The home is finding staff recruitment difficult and at the time of the inspection has two vacancies for care staff. Both the providers and the manager provide hands-on care, when necessary. The inspector and registered manager discussed alternative recruitment sources and ideas to address the recruitment difficulties. Lorne House has clear recruitment policies and procedures, which are followed when appointing staff. The previous inspection required staff to comply with the TOPPS (Sector Skills Council) training specifications. This has been organised through Stourbridge College i.e. the Induction and Foundation training, and one member of staff is currently completing this. The training plan aim is to complete the Induction and Foundation course and then develop staff up to NVQII level. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 Page 19 Staff training and guidance in dealing with death and dying as recommended in the previous inspection has been met, with staff completing a bereavement course at Woodfield House. There is evidence of regular staff supervision, together with annual appraisals. A revised appraisal format has been completed and this was shared with the inspector. The inspector considers the revised format will strengthen the appraisal process. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 42 The home is well managed, with an open and positive approach. There are clear lines of accountability, which promotes quality and consistency of care. The manager is currently completing the registered Managers Award, which is seen as a benefit to residents and the staff team when achieved. Requirements and recommendations from the previous inspection have been met, with the exception of the development of a quality assurance system, and food hazard analysis. EVIDENCE: The manager and provider spent time with the inspector and were open and cooperative in their approach, contributing towards a positive inspection experience. The manager is completing the Registered Managers Award and is aiming for completion by December 2005. There is evidence that this training is proving LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 Page 21 to be beneficial for standards of practice and therefore the benefit of residents and the staff team. A framework for a quality assurance system has been established but needs further development. This was a requirement of the previous inspection, and although not fully completed at the time of the inspection, work is ongoing. A copy is to be forwarded to the inspector on completion. The previous requirement that the registered provider must review risk assessments, including the fire risk assessment has been met. Risk assessments were seen by the inspector and considered to be satisfactory. It is considered good practice to review the fire risk assessment when there is a new admission to the home. The home has a smoking policy and a risk assessment for those residents and staff who smoke has been completed. The inspector advised that a separate risk assessment is completed for the resident who smokes in the event that he may smoke in his bedroom instead of the designated smoking area. The previous inspection required the registered manager to ensure that: • • • • • • All soft furniture such as chairs provided by the home meet the Furniture and Furnishing (Fire Safety) Regulations 1988 (as amended in 1989 and 1993) Control of Substances Hazardous to Health risk assessments and hazard data sheets are in place All hazardous items are stored away at all times when not in use Portable appliances and gas appliances are inspected and tested, and accurate records are maintained Up to date public liability insurance certificate is on display. The Home checks the washing machine complies with the Water Supply (Water Fittings) Regulations 1999. All these requirements have been met. A Food Hazard Analysis assessment, under assured safe catering needs to be developed, reviewed and maintained as per previous requirement. In order to meet this requirement the registered manager is seeking information from EHO. A vertical handrail outside the bedroom door on the upper floor should be fitted to provide extra safety where the staircase is unusual and steep. The storage area to the small landing opposite the bedroom, which is obstructed by a handrail, must be discontinued as it poses a health and safety risk to people reaching for the items, which are stored there. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 Page 22 LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 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 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score 3 x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 LORNE HOUSE Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 2 x E52 S18509 Lorne House V236879 050705.doc Version 1.40 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 Requirement Timescale for action 31.12.05 2. YA24 23 (2) (p) 3. YA39 24 4. YA42 13 The registered manager must ensure service users care plans cover all aspects of care as set out in standards 6 and 2.3, is drawn up with the involvement of each user in a format that can be understood by or explained to residents. All care plans must be reviewed with the resident at their request or at least once every six months, and updated to reflect changing needs. (previous timescale of 31.03.05 not met) The registered provider must 30.09.05 ensure that the outer conservatory is suitably heated. (previous timescale of 31.03.05 not met) The framework for a quality Ongoing assurance system, which has been established must be developed. (previous requirement not fully met) The registered manager must 30.9.05 ensure that a Food Hazard Analysis Assessment, under assured safe catering is developed, reviewed and maintained. (previous timescale of 31.03.05 not met) Version 1.40 LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Page 25 5. YA24 23 (2) (d) 6. 7. YA42 YA42 13 (4) 13 (4) The wall of one of the residents bedroom must be repainted where the radiator has been removed. A handrail must be fitted to the top of the stairs to maintain safety for resident and staff. Items stored on the top stair landing must be removed as the landing is not a safe storage area. 30.8.05 31.08.05 31.07.05 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. 4. 5. Refer to Standard YA32 YA20 YA40 Good Practice Recommendations The registered provider should prepare an action plan as to how 50 NVQ target will be met by 2005 It is considered good practice to highlight allergies recorded on MAR sheets for ease of identification. Policies should be drawn up in respect of bullying and in respect of emergencies and crises. LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 Page 26 Commission for Social Care Inspection The Coach House John Comyn Drive Droitwich Road Worcester WR3 7NW 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 LORNE HOUSE E52 S18509 Lorne House V236879 050705.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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