Inspection on 03/09/07 for Magnolia House

This inspection was carried out on 3rd September 2007.

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

Other inspections for this house

Magnolia House 22/11/06

Magnolia House 22/11/05

Magnolia House 11/07/05

Magnolia House 30/01/05

Magnolia House 27/07/04

Magnolia House 08/01/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Magnolia House 11 Station Road Biggleswade Bedfordshire SG18 8AL Lead Inspector Andrea James Unannounced Inspection 3rd September 2007 10:00 Magnolia House DS0000014934.V350168.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 Magnolia House DS0000014934.V350168.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. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Magnolia House Address 11 Station Road Biggleswade Bedfordshire SG18 8AL 01767 315562 01767 317586 vendersby@hotmail.com www.communitycaresolutions.com Community Care Solutions Limited 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) Manager post vacant Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (2) of places Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home can accommodate a maximum of 7 people, 5 in the main house and 2 in the bungalow. The home can accommodate a maximum of 7 people in the category learning disability (LD) The home may accommodate up to 1 person who has a physical disability or sensory impairment if their primary assessed need is a learning disability. This person must be accommodated in the ground floor bedroom of the main house. The bungalow must only be used for those service users that are working towards more independent living as part of their agreed plan of care. The home may accommodate up to 2 persons with Mental Disorder (MD). 22nd November 2006 4. 5. Date of last inspection Brief Description of the Service: Magnolia House was first registered in 1999 to provide residential care to 5 adult users - 3s with learning disabilities. The home now provides care to 5 users and an additional 2 in an adjoining bungalow. The home is a family house which has been extended to provide five single bedrooms, one of which is on the ground floor, a large kitchen/diner, lounge and conservatory. There are bathing and toilet facilities on both floors and a small office/sleep-in room on the first floor. The home is within walking distance of Biggleswade town centre, with its shops, library, pubs and places of worship. The current service user group are all between 25 and 50 years and all have learning disabilities. They also need varying degrees of support with behaviour that may be challenging. The home aims to enable people to live as independently as possible whilst receiving care and support to enable them to access the local community. The fee was in the range of £ 946/- to 1,628/-. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 3rd of September 2007. The inspection lasted for the duration of 6 hours and the manager was present throughout the inspection process. The inspection followed a case tracking methodology where a sample of the people using the service were case tracked. They were spoken to and their files inspected and where possible their key workers were also spoken to. The report consists of information received from the AQAA (Annual Quality Assurance assessment), staff and users surveys and other evidence collected since the last inspection. The inspector would like to thank the people using the service, the care staff and the manager for their cooperation and contribution to the inspection process. What the service does well: What has improved since the last inspection? Since the last inspection the home had applied to the Commission for Social Care Inspection in response to their outstanding requirement to vary their conditions of registration to include users with mental health. The home had also ensured that care staff training development was implemented in a proactive way. Records seen suggested that all staff received mandatory training and some staff had embarked on training in meeting the changing needs of the people who use the service. The home had records to Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 6 suggest these training courses were ongoing and staff spoken to said they received training on a regular basis. 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. The summary of this inspection report can be made available in other formats on request. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 &5. People who use this service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Satisfactory processes were in place to ensure users had sufficient information to make a choice about using the service and there needs were comprehensively assessed, as a result users needs were met. EVIDENCE: The home had a Statement of Purpose and a Service User Guide. A copy of the User Guide was available on all files and was presented in a pictorial format to ensure users could understand its contents. The three files inspected had comprehensive assessments available which showed a clear history of the users needs. There was also evidence to suggest these were reviewed and documents were up-dated when necessary. The files of one user who was admitted to the home three months ago showed that satisfactory assessments were undertaken. The user spoken to said she was provided with sufficient information about the home and was happy to move in. All users had contractual agreements and files inspected suggested that users were invited to sign their contracts with the home. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9. People who use this service experience a poor quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The home ensured people using the service were given the opportunities to make decisions, participate in life at the home and develop their independence. However further development was needed to ensure care plan documentation and risk assessments reflect the care to be carried out for all users in ensuring consistency, as a result users needs could go unidentified and unmet. EVIDENCE: There were satisfactory processes in place to ensure users were enabled to make decisions about their daily lives. One user said he was able to make a decision about going on holiday. Another user was able to make a choice when to go for a walk and what he wanted to have for his evening meal. Staff were also observed asking the less able users what they wanted to eat or what activity they wanted to carry out. There was evidence to suggest the home had considered Person Centred Planning approach for some users but this was in its early stage. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 10 The users spoken to said they were enabled to participate in activities such as attending day centres and visiting family and friends. The manager informed the inspector that all users recently contributed to their Hawaiian night by helping to make the decorations for the event. The home also implemented risk assessments to enable users to take assessed risks but these were unsatisfactory as the number of risk assessments seen defeated the object of the exercise. The inspector counted 27 to 39 risk assessments for each user and some were irrelevant as they only stated that there were no risks in some areas. The assessments seen also failed to clearly identify the risk and the level of risk posed to the user, as a result care staff would find it difficult to identify the severity of risk posed to users. The care plan documentation seen suggested that users were consulted about the care to be delivered and in some case the users signed their agreement, however further development was needed to ensure clear staff interventions are recorded. The records seen only highlighted the assessed needs and the goals but the intervention was not recorded. This could result in inconsistent service delivery from the staff team. The inspector spoke to staff about their knowledge of the users and although all were able to demonstrate a level of knowledge they were not consistent in their approaches. This could therefore be as a result of the lack of clear instructions provided from the care plan documentation. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14 &17. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Good systems were in place to ensure opportunities were available for personal development, access to the community, leisure activities and to maintain a healthy diet, as a result users lifestyle was in line with their required needs. EVIDENCE: The home provided various opportunities for users to develop and achieve their goals. Those spoken to explained that they attended colleges, various day centres and some were able to do their own shopping and access various community resources. The care staff expressed however that users are restricted from accessing resources as much as they would like due to the fact that only one member of staff was able to drive. The manager said they were in the process of recruiting and hoped that this issue would be resolved in the future. The home was also Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 12 due to receive a new vehicle that would better accommodate the people using the service. The inspector observed care staff offering users a choice of activities. Some users were observed in an art and craft session. The inspector was informed that users helped with house chores in order to develop personal skills. The inspector was informed that the diverse needs of users were also met in regards to users religious and cultural needs. One user was enabled to attend church with a staff member, the staff were dedicated to this in such a way that they would come into the home on their days off to facilitate this activity. The home provided nutritional needs for users. One user said she had recently reviewed her weekly menu and included meals that she liked. The home consulted users about their nutritional requirements through residents meetings and one to one conversations. The inspector was informed that users were able to have spicy food as a recent request in the residents meeting. The home had a large stock of various foods to suggest users were given a variety. Some users were seen accessing provisions independently. Users spoken to said they regularly visited their family. One user was given news on the day of the inspection that his brothers and sisters were trying to get in touch and he had given permission for the home to provide the information required. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. The assessed needs of users personal health were met as outlined in the care plan documentation, however further development was needed to ensure all procedures for medication safeguard the people using the service, as a result users could be at risk. EVIDENCE: The home had procedures in place to ensure users received support for personal health. The records inspected showed that users signed contracts that enabled them to engage in various activities. Users were able to have the opportunity to go into the community. All except one user was supported outside the home and the one user who refused to leave the home was also enabled to live a full lifestyle in the way he preferred. The records inspected suggested that various review meetings with external professionals were held on a regular basis to ensure the emotional and health care needs of users were met. These were satisfactorily documented and recommendations were implemented in the form of guidelines for the care staff Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 14 to follow. For example one user who placed demands on carers due to high anxiety had in place guidelines that suggested that all staff should spend 15 minutes with him and records clearly stated how to answer his questions and conversations to avoid. The home had policies and procedures for receiving, administering and disposing of medication and all medications were securely locked. However further development was needed as care staff spoken to were not clear about the procedures to follow in receiving and disposing of medication in the home. The inspector also counted 5 PRN medications that were outdated by over a year and should have been returned to the prescriber. Staff could not explain if these medications were in use or when the user had a review to determine their relevance. Staff said they had not received formal training in these procedures because the medication was only left to the manager and one other care staff in the home, despite the fact that all staff administered medication. The procedures for storing and administering controlled drugs were satisfactory. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. Systems were in place that ensured people using the service were listened to and protected against abuse, but further development was needed to ensure all aspects that adversely affect users are reported to the right authorities, as a result users safety could be compromised. EVIDENCE: The home had satisfactory policies and procedures in place for receiving and dealing with complaints. Users spoken to said they were made aware of the complaints procedure and copies were seen in the users files. They also commented that they would speak to the carers and manager if they had a complaint. The home had reported some issues of safeguarding to the appropriate authorities but records inspected suggested that staff had identified incidents that were only recorded and kept on file but had not been reported using the “Safeguarding” procedures. The training records inspected suggested only a small number of carers received “Safeguarding” training, which could reflect in the current procedures been used. The procedures in place to protect users finances were satisfactory. Three users finances inspected were clearly recorded and had a good audit trail. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28 &30. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence including a visit to the service. The standards maintained ensured users lived in a comfortable and safe environment, however further development was needed to ensure users are safeguarded from scalds and all areas of the home are welcoming, as a result users comfort could be compromised. EVIDENCE: The home had a warm and welcoming feel and was free from offensive odours. The inspector observed that some users took pleasure in keeping their environment clean. All users were responsible for keeping their bedrooms tidy. The inspector was invited to view some users bedrooms, which had evidence of personal belongings, one user had a personal pet bird in her bedroom. The inspector was informed that plans were ahead for redecorating the communal areas of the home. There were also plans to redecorate the kitchen Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 17 in the main house and remove the existing washing machine and dryer out of the food preparation area. Some furnishings in the home also appeared worn and discoloured. The inspector identified that one tap in the bathroom distilled water that was of excessive temperature that could cause scalding or burn to users. The electrical appliances in the flat where two users lived had not been checked in line with the annual requirement. The home also had one door that did not shut on its rebate. The inspector had also been informed that the organisation had employed quality assurance personnel who had been to inspect the environmental standards of the home. They had identified areas of the home that needed to be addressed namely replacing carpets and windows. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 &36. People who use the service experience a poor quality outcome in this area. We have made this judgement using a range of evidence. To include a visit to the service. People using the service were supported by a core of staff that were qualified and competent in their roles, however further development was needed to ensure sufficient number of trained staff are available to meet the needs of the users, as a result users needs could be compromised. EVIDENCE: The home had a core of staff that provided a satisfactory standard of care to people using the service. They were in turn supported by the manager and all staff spoken to said the manager was supportive and approachable. There was evidence to suggest care staff received regular supervision and appraisals. All staff spoken to said they benefited from their supervision sessions. The manager had a record of all supervision and dates for future supervisions to be undertaken. The home recently lost three care staff through disciplinary procedures and as a result was short staffed. The manager said she was in the process of Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 19 recruiting and during the inspection received an application form. The rota required 3 care staff in the mornings 3 at midday and 3 in the evenings but the home had been working with 2 in the mornings, sometimes 1 at midday and 2 in the evenings. The inspector was also informed that two staff were due to go on maternity leave, which would make the staff shortages more severe. This was concerning because some of the users displayed high levels of anxiety and sometimes displayed behaviours that challenged the service. The staff records inspected suggested that minimum information was available for inspection. The manager said head office kept all staff details and she did not receive any evidence of satisfactory clearances prior to staff commencing employment. She was however very confident that these clearances had been undertaken before staff were allowed to commence employment. The inspector also failed to see evidence of staff induction files which again was said to be kept at the head office. The home had made improvements on the training opportunities available to the staff team. All staff spoken to said they had received training in various areas but these were mainly mandatory courses. There was however a need for further training to be undertaken in meeting the changing needs of the people who use the service. The home currently had 2 users’ assessed with shizophrenia and 2 users’ assessed with autism. The home should plan to train additional staffs in tune with the assessed needs of the users’. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,42 & 43. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. The home had managed well and the people using the service were supported by an established team and underpinned by clear policies and procedures, however further development was needed to ensure the users views are monitored and all areas of the home are safe, as a result users best interest could be compromised. EVIDENCE: The home had changed managers since the last inspection. The current manager appeared competent and knowledgeable about the needs of the people using the service. She has been in post for 6 months and has applied for her registration. She has a Registered Managers Award qualification and is hoping to commence her NVQ level 4 in management in the near future. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 21 The home did not have a quality assurance policy but had implemented various aspects of monitoring the views of both users and the staff team. For example weekly activity reviews, weekly management checklist, drug checks and temperature checks. The home also had a 10-year maintenance programme that highlighted areas to be implemented in a systematic format in the home. The manager informed the inspector that questionnaires had been issued to users of the service and were sent to the head office but had not received the findings. The home had clear policies and procedures that were reviewed and updated centrally on a regular basis. Staff said they were made aware of the changes to policies through staff meetings. The home had implemented various procedures that underpin good health and safety legislations. There was evidence to suggest fire evacuation and fire testing were carried out on a regular basis. It was however concerning to note that one fire door failed to close on its rebate. The inspector observed that a hot water tap distilled water that was hot enough to cause scalding to users. The manager and staff appeared to work as a team and had good working relationships that benefited the people using the service. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 1 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 1 3 X 1 3 Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 23 NO 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 (1) Requirement Arrangements must be made to ensure clear care interventions are recorded for all users within their care plan documentation. Arrangements must be made to ensure all users risk assessments are clear and specific in identifying the level of risk. Arrangements must be made to ensure all PRN medication procedures are reviewed and reflect a safe practice for users of the service. Arrangements must be made to ensure all incidents that adversely affect the safety of the people using the service are reported using Safeguarding procedures. Timescale for action 30/10/07 2 YA9 13 (4) (a) (b) (c) 30/10/07 3 YA20 13 (2) 30/10/07 4 YA23 13 (6) 30/10/07 5 YA24 23 (2) (b) Arrangements must be made to 30/10/07 ensure all aspects of the home are safe and well maintained to a satisfactory decorative state. Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 24 6 YA28 23 (1) Arrangements must be made to replace or repair worn and discoloured furnishings in the home. The home must make arrangements, by training adequate staffs’ to work with users’ who have mental health needs. Previous timescale:15/01/07 Arrangements must be made to ensure sufficient numbers of staff are employed in the home to meet the needs of people using the service. 30/10/07 7. YA32 13 (6) 30/10/07 8 YA33 18 (1) (a) 30/10/07 9 YA34 19 (1) ( c) Satisfactory recruitment 30/10/07 procedures must be available in the home to ensure evidence can be obtained of the authenticity of all staff employed by the organisation. 18 (1) (c ) Arrangements must be made to (i) ensure the staff development plan includes training in safeguarding and safe medication procedures. 24 (1) Effective quality assurance systems, policies and procedures must be in place that seeks and monitors the views of people using the service Effective health and safety procedures must be in place to prevent users from scalds and burns. Arrangements must be in place to ensure all doors close on their rebate in line with fire regulations and safety. 30/10/07 10 YA35 11 YA39 30/11/07 12 YA42 13 (4) (a) 30/10/07 13 YA42 23 (4) (a) 30/10/07 Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 25 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 YA9 Good Practice Recommendations Arrangements should be made to review the number of risk assessments available in the care plan documentation, in ensuring their relevance. Evidence of satisfactory Induction programmes for new staff members should be available for inspection. 2 YA33 Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Magnolia House DS0000014934.V350168.R01.S.doc Version 5.2 Page 27 - 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. 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