Inspection on 27/09/06 for Lynwode Park

This inspection was carried out on 27th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lynwode Park 27/11/07

Similar services:

Oakmount Hostel

Ark House

St Anne`s Alcohol Services - Leeds

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

CARE HOME ADULTS 18-65 Lynwode Park Wensley Road New Lodge Barnsley South Yorkshire S71 1TJ Lead Inspector Mrs Sue Stephens Key Unannounced Inspection 27th September 2006 09:30 DS0000066643.V308614.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 DS0000066643.V308614.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. DS0000066643.V308614.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lynwode Park Address Wensley Road New Lodge Barnsley South Yorkshire S71 1TJ 01226 779450 01226 779469 info@lynwodemanor.co.uk 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) Mimosa Recovery Ltd Mr William Marsh Care Home 7 Category(ies) of Past or present alcohol dependence (7) registration, with number of places DS0000066643.V308614.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The porch to the entrance of Lynwode Park must be completed within 3 months of the date of registration. The adjourning care home, Wensley Park, must not be used as a thoroughfare to Lynwode Park. Access and exit to Lynwode Park will be via its own entrance. Lynwode park must be staffed by a dedicated nursing/care staff team (not nursing/care staff from Wensley Park). Lynwode Park opened in March 2006 and this was the homes first inspection. Date of last inspection Brief Description of the Service: Lynwode Park is a registered care service for people with past or present alcohol dependence. The home provides the primary stage for detoxification and therapy. The home provides care for men and women. Lynwode Park is on a housing estate on the outskirts of Barnsley. It accommodates the 1st floor of a large House. The ground floor accommodates a registered care home called Wensley Park. Mimosa Health Care owns both care homes. There is a separate entrance for Lynwode park, and the access is by stairs. There are 7 single bedrooms. Each bedroom has an en-suite. All of the ensuites have washbasin and toilet; one of the en-suites has a shower. Shared bathroom and shower facilities are available close to the bedrooms. There is a dining and kitchen area where clients can make drinks and snacks. The lounge is the designated smoking area. Non-smokers can use the therapy room as a lounge when it is not in use. The local amenities include shops, chemist, library, church, and a bus route to town. Lynwode Park does not encourage clients to use the local amenities during their stay. This is because of the nature of the treatment and therapy. The home does make special arrangements for people to attend church if needed. The manager provided the information about the homes fees and charges on 08th August 2006. Fees are £1800 per week. Additional charges include newspapers. DS0000066643.V308614.R01.S.doc Version 5.2 Page 5 Prospective clients and their families can get information about Lynwode Park by contacting the manager. The home will also provide a copy of the statement of purpose and the latest inspection report. Further information about the home can be found at www. Lynwodemanor.com DS0000066643.V308614.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced; it took place between 9:30am and 18:00pm. The inspector sought the views of the 5 clients, staff nurse, therapist, and support worker. The manager was on leave and the Staff Nurse Christina Smith assisted the inspector with the visit. Phil Barren, a temporary manager, was covering whilst the registered manager was on leave. During the visit the inspector looked at the environment, and made observations on the staffs’ manner and attitude towards the clients. The inspector checked samples of documents that related to the client’s care and safety. Accommodation normally lasts for 7 days; because of this the inspector did not issue questionnaires about the home to the clients prior to the visit. The inspector did not seek the views of external visiting professionals because they had not been involved with clients at Lynwode Park. At the start of the visit a company director, Sue Allchurch, gave information about the homes future plans. These included plans to extend the home and increase the bed numbers. The registration inspector Pat Pedley was present at this point. The inspector checked a sample of records. These included three assessments and care plans, three medication records, and three staff recruitment files. The inspector looked at other information before visiting the home. This included the pre-inspection questionnaire, which the Commission for Social Care Inspection (CSCI) had requested. Five clients received care at Lynwode Park at the time of the visit. This was the homes first inspection and the inspector checked all the key standards. The inspector acknowledged that Lynwode Park was a unique and special service in comparison to general care homes. And took this into account when checking the home against the National Minimum Standards. The inspector would like to thank the clients and staff for their help and contribution to the inspection. DS0000066643.V308614.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? This is Lynwode parks first inspection. DS0000066643.V308614.R01.S.doc Version 5.2 Page 8 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. DS0000066643.V308614.R01.S.doc Version 5.2 Page 9 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 DS0000066643.V308614.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The quality outcome of this area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. Prospective clients do not have all the information they need to decide if Lynwode Park can meet their needs. The clients have their needs assessed; however the contract is not clear enough about the service they will receive. EVIDENCE: Lynwode Park had a good system to assess peoples’ needs. The assessment procedure took into account that most people were selfreferral and self-funding. Both the nurses and the therapy staff assessed the clients’ needs. And each client had a consultation with the organisations clinical psychiatrist. The assessments included the client’s diversity needs, for example religious and spiritual needs, disabilities and gender. This was good practice. The clients said they were satisfied with how Lynwode Park carried out their assessments. DS0000066643.V308614.R01.S.doc Version 5.2 Page 11 Some clients said they were disappointed about Lynwode Park facilities compared to the information they received about the home. For example two clients said they read about the home on the website; it said bedrooms were en-suite. This led them to believe they would have private shower facilities; however the en-suites for most rooms had sink and toilet only. Another client said they had been confused about whether they could have visitors or not. The inspector looked at some of the clients’ limitations of freedom and choice. These included restrictions on visits to the local community and local amenities, restrictions on visitors, and restrictions on self-administering medications. The clients said they were not aware of some of these limitations until after their admission. The inspector acknowledged that limitations on freedom and choice might be an essential part of an individual’s treatment; however this was not clear in the information about the home and in the clients’ contracts. The nurse and therapist’s view about receiving visitors was not consistent. Some of the wording in the contract was difficult to understand what it meant. The contract had the name of a different home on it. One client said he found the writing small. One client said he wasn’t told until the day he arrived that he could not have visitors, however this contradicts the information given to him in the information file. One client said there were pages missing in his information file, so he did not have all the information. DS0000066643.V308614.R01.S.doc Version 5.2 Page 12 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 and 9 The quality outcome of this area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Individuals are involved in decisions about their lives. However they do not have enough access to their care plans to help them to be involved in the care and support they receive. EVIDENCE: Clients had a care plan for their treatment. This was a general care plan; the nurse confirmed that they added any additional needs identified in a client’s assessment. For example if some one had diabetes or other medical or disability needs. The care plans and other information about the clients was securely stored. The nurses and therapists made daily records about the person’s progress. The home had risk assessments suitable for the high independence and short stay needs of the clients. DS0000066643.V308614.R01.S.doc Version 5.2 Page 13 Only one person out of the five clients interviewed had seen their plan. The nurses had not explained the care plans to the clients. The clients said they had not read or signed them. The clients said the nurses and therapist respected the clients’ decisions. They said the nurses explained things and “went out of their way” to help. DS0000066643.V308614.R01.S.doc Version 5.2 Page 14 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): 12,14,16 and 17 Standards 13 and 15 were not applicable to the needs of the clients in this service. The quality outcome of this area is poor. This judgement has been made from evidence gathered both during and before the visit to the service. Educational and recreational activities did not meet the clients’ expectations. EVIDENCE: The clients said that although the therapy sessions were helpful, they did not get all the sessions they were suppose to. The therapy session timetable was in the information file provided in the clients’ bedrooms. DS0000066643.V308614.R01.S.doc Version 5.2 Page 15 The clients gave examples of missed sessions; they said one day a session was due at 10am but they did not get anything for some hours later. One client said they were “just left waiting in the lounge”. Out of the five clients only one said they had received a 1 to 1 therapy session. One client said about Lynwode Park’s sister home “we always knew what we were doing; here we don’t know when we will be called into therapy”. Another client said the frequency of the sessions was “poorly managed”. And another client referring to the therapy timetable said “the day doesn’t follow the format”. The inspector checked this information with the therapist. The therapist confirmed that some sessions were late or missed. Some clients said they found the therapy sessions repetitive. The inspector checked with the therapist what tools and resources they used. The therapy resources were insufficient. There were no educational tools, visual aids or other materials to provide the clients with good information, education, and an understanding about their condition. The clients said in-between therapy sessions there was very little to do. They said the T.V stations were limited and there was very little reading material, for example magazines and books. One client said he was use to doing daily exercises and some exercise equipment would be useful at the home. The clients said they liked to go out for some fresh air, however there was nowhere to sit in the garden. The clients suggested the following would be useful to help people relax and pass the time, books, magazines, digital-box, supply of DVDs, dartboard, exercise equipment, and pool table. The clients said they were satisfied with the meals. They confirmed the meals were nutritious and they said, “There is plenty to eat”. There were facilities for the clients to make their own drinks and snacks. The mealtimes were sociable and relaxed, and clients could have their meals in their own room if they wished. The clients did not know what meals they were going to have. No menu was provided. This made it difficult to express choice or inform the cook if they wanted an alternative meal. DS0000066643.V308614.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 The quality outcome of this area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The health and personal care meets the clients’ individual needs; and staff treat them with dignity and respect. Some medication records were not safe, and clients need information about G.P access. EVIDENCE: The clients said they were satisfied with the care they received. They said the staff were “really good”. One client said “they really go out of their way” and “they can’t do enough for you”. The clients said that during the intense part of their treatment the nurses were very “attentive” and regularly checked on the clients. Because the average stay of a client was seven days, there was no regular contact with other outside clinical and social professionals. However the home did have an agreement with a local G.P. The clients did not have this information, and they were unaware that they could access a G.P. DS0000066643.V308614.R01.S.doc Version 5.2 Page 17 All clients said the staff treated them with dignity and respect. Medication records were not robust enough to ensure the clients safety. On receipt of medication, nurses had not recorded the date and amounts. And when transferring medication details to administration charts they did not get a witness to check sign that the details. Homely remedies were not managed in line with the Royal Society of Pharmaceutical guidelines. This could put clients health at risk. DS0000066643.V308614.R01.S.doc Version 5.2 Page 18 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 The quality outcome of this area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. People who use the service did not have enough information to help them express their concerns. Staff training and guidance was insufficient to safeguard clients from the risk of abuse. EVIDENCE: The home did have a complaints procedure. However the clients said they did not have clear information about what to do if they needed complain. One client said the complaints procedure was in the information file; however another client said some of his information was missing. The inspector interviewed one staff member who was not clear about the homes complaints procedures. The home did have adult protection policies and procedures however staff had not had training or guidance and one staff member was not clear about the principles of adult protection. DS0000066643.V308614.R01.S.doc Version 5.2 Page 19 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): 24,26 and 30 The quality outcome of this area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The home, in the main, is clean and comfortable. Some of the physical design and facilities need to improve to benefit peoples health and comfort. The home is not free from offensive smells. EVIDENCE: The clients said in the main the home was clean and comfortable. They said there rooms were pleasant and their beds comfortable. One client said “the staff asked you every day if you wanted your sheets changing and they changed your towels daily”. The clients said there was only one shower, which was small and uncomfortable. However the home plans to expand the Lynwode Park, which would include more bathing facilities. In addition to the shower there was two other communal bathrooms. DS0000066643.V308614.R01.S.doc Version 5.2 Page 20 The main lounge was also the designated smoking room. Non-smokers could sit in the therapy room when it was not in use. The lounge did not have an extractor fan and the clients said it got very “smoky” at times. This arrangement was not adequate for non-smokers, however the proposed extension of Lynwode Park would address this matter. The clients said that there was no seating outside in the garden. Some clients said they felt there was insufficient security around the building, for example in the car park and the entrance. Clients could use the homes phone to make private phone calls, however this meant asking office and other staff to leave the office. This arrangement was not suitable to allow people to make private phone calls. The clients and staff said sometimes there was a smell of urine. This was in some bedrooms and also near the entrance to the home. The porch to the entrance of Lynwode Park was completed within 3 months of the date of registration. This was a condition of the homes registration. DS0000066643.V308614.R01.S.doc Version 5.2 Page 21 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, 34 and 35 The quality outcome of this area is poor. This judgement has been made from evidence gathered both during and before the visit to the service. Care provided by staff met the expectations of the clients. However the lack of National Vocational Qualifications and training puts staff at risk of following poor practices. And puts clients at risk of receiving inconsistent and unsafe care. EVIDENCE: The clients said they were happy with the staff. They made very positive comments, which included, they are “excellent”, “they go out of their way”, “I feel safe”, “they will do anything for you; you just have to ask”. The nurse and therapist had good knowledge about alcohol dependency. They understood their roles, had a positive attitude and understood the diversity needs of the clients. For example their religious background or disability needs. The care staff did not have National Vocational Qualifications at level 2 or above. However the nurse said Mimosa Recovery Ltd had planned to provide access to the qualification and include alcohol misuse modules. DS0000066643.V308614.R01.S.doc Version 5.2 Page 22 The home had good recruitment records that showed how they had followed robust recruitment procedures. One file did not have the reason for employment gaps recorded. This meant the home could not fully vet individual staff to make sure they were suitable for the job. Staff had training certificates from previous posts. However there had been very little training provided to staff at Lynwode Park, and there was no future training plan available. One staff member confirmed this and said they were not aware of any training since the home had opened. The home opened in March 2006. This was poor practice. Update training is essential to make sure staff understand the complexities of the clients’ condition and provide consistent and up to date care and therapy. Lynwode park was staffed by a dedicated nursing and care staff team, this met the homes condition of registration. DS0000066643.V308614.R01.S.doc Version 5.2 Page 23 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 The quality outcome of this area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. There needs to be better management and leadership. This will provide better safeguards for the clients’ safety and welfare. EVIDENCE: Through the Commission for Social Care Inspection registration process the manager demonstrated he was qualified and experienced to manage the home. The manager had been on leave for over 28 days and the home had appointed a temporary manager to cover for a period of about six weeks. DS0000066643.V308614.R01.S.doc Version 5.2 Page 24 This inspection visit identified several areas where the home was not meeting National Minimum Standards. The absence of the manager and clear leadership was evident. For example the confusion about receiving visitors and other limitations of freedom and choice, the lack of therapy resources, inconsistent therapy sessions, poor complaints procedure information, and minimum staff training. The home did have quality assurance systems in place; this included a client survey issued to each client following their stay. The Nurse said these were collected and comments followed up. The nurse said in the main the feedback on the questionnaires was positive. The home had systems in place to manage safe-working-practices; for example a maintenance book, health and safety policies and procedures, and fire drills. However staff had not received up to date safe-working-practice training since the home had opened and there was no safe-working-practice training plan available. DS0000066643.V308614.R01.S.doc Version 5.2 Page 25 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 2 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 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 X X LIFESTYLES Standard No Score 11 X 12 1 13 N/A 14 1 15 N/A 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 3 X X 2 X DS0000066643.V308614.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Not applicable. 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 YA1 Regulation 5 Requirement Clients must be given clear written information about their limitations on freedom and choice. If visitors are not allowed or encouraged to visit during the clients stay, this must be made clear in the homes statement of purpose. And it must be agreed as part of the individual’s contract/arrangement. Information in the clients’ contracts must be easy to understand. The contract must have the correct name of the home on it. The clients must be informed about their care plans and they must be invited to sign them. Clients must be provided with the therapy sessions and one-toone support that is agreed as part of their care package. Suitable equipment and DS0000066643.V308614.R01.S.doc Version 5.2 Page 27 Timescale for action 30/11/06 2 3 YA6 YA12 15 13,13 and 16 30/11/06 30/11/06 4 5 YA14 YA17 12 and 16 12 7 YA19 13 8 YA20 13 resources for the therapy sessions must be provided. Suitable leisure resources must be provided. The clients must be given a menu and they must be informed about alternative choices. The clients must be informed about the homes arrangements for contacting a G.P. during their stay at the home. The recording of medication onto medication sheets must be checked and signed by two staff. On receipt of medication staff must record the amount, date, and signature of staff member. Homely remedies must be stored, recorded and administered in line with the Royal Pharmaceutical guidelines. Clients must be given clear information about how to raise a concern or complaint. All staff must be informed about the homes complaints procedure and how to deal with complaints. All staff at the home must receive adult protection training or guidance. Suitable outside seating for clients must be provided. The smoke room must be fitted with an extractor fan. Facilities to enable clients to make phone calls in private must be provided. The smell of urine in the home must be investigated and action taken to eliminate it. Suitable non-smoking communal areas must be provided. DS0000066643.V308614.R01.S.doc 30/11/06 30/11/06 30/11/06 31/10/06 9 YA22 22 30/11/06 10 11 12 YA23 YA24 YA26 13 16 16 30/11/06 30/11/06 30/11/06 13 YA30 13 30/11/06 Version 5.2 Page 28 14 YA32 18 15 16 YA34 YA35 19 18 Arrangements must be made to make sure care staff achieve the appropriate National Vocational Qualifications. Employment gaps must be explored and the reasons recorded. A staff training and development programme must be put in place. This must meet the training needs of the staff and must be linked to the homes aims and clients needs. An quality assurance audit must be carried out to make sure the home meets the National Minimum Standards. 30/11/06 30/11/06 30/11/06 17 YA37 10 30/11/06 18 YA42 13 Consistent leadership must be provided in the absence of the manager. All staff must be given up to date 30/11/06 safe practice training. This must include: Moving and handling First aid Fire training Food hygiene Infection control DS0000066643.V308614.R01.S.doc Version 5.2 Page 29 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 Refer to Standard YA1 Good Practice Recommendations The home should make sure the black information folders are up to date and contain all the relevant information for each new admission to the room. The homes information should be clear that most en-suite facilities do not have a shower. This should include information supplied on the website. Therapists should record in the client’s records the reason for missed, altered or shortened sessions. This will help the home to audit and monitor the sessions. The home should look at the external security of the building and make any identified improvements. 2 3 YA12 YA24 DS0000066643.V308614.R01.S.doc Version 5.2 Page 30 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 DS0000066643.V308614.R01.S.doc Version 5.2 Page 31 - 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!