Inspection on 22/05/06 for Maple House

This inspection was carried out on 22nd May 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 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Maple House 11/04/08

Maple House 17/05/07

Maple House 21/11/05

Maple House 18/05/05

Maple House 18/11/04

Maple House 14/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Maple House 51 Peveril Road Tibshelf Alfreton Derbyshire DE55 5LR Lead Inspector Anthony Barker Unannounced Inspection 22nd May 2006 09:05 Maple House DS0000020051.V293313.R01.S.doc Version 5.1 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 Maple House DS0000020051.V293313.R01.S.doc Version 5.1 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. Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Maple House Address 51 Peveril Road Tibshelf Alfreton Derbyshire DE55 5LR (01773) 872720 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) Mr Peter South Mr Peter South Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The requirements and recommendations of the Environmental Health Officer must be met. All areas of the enlarged premises must be fully furnished and decorated including floor coverings. Restrictors must be fitted to all first floor windows. All building materials and equipment must be removed from garden areas. Timescale for this work: six months from the date of this certificate. A maximum of four persons are to be accommodated until all the above work is completed. 21st November 2005 Date of last inspection Brief Description of the Service: Maple House is a care home situated in Tibshelf village near Alfreton. The Home is a semi-detached house on an estate at the edge of the village. It has recently had an increase in registered service users from 3 to 5 following an extension to the premises. The two current residents in the Home receive day services for five days of the week and are supported at other times to undertake activities within the local community. Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 7.5 hours and was a key unannounced inspection. The last inspection took place in November 2005 and was unannounced. Two residents, the Manager and the Deputy Manager were spoken to and records were inspected. There was also a tour of the premises. Both residents were case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Care plans must be regularly reviewed and must reflect how residents’ health and welfare needs are being met. Efforts must be made to find out what specialist health services are being provided to each resident and records of these details maintained on care plans. Outstanding improvements to the environment must be undertaken and the rear garden made safe for residents. The Home must obtain a certificate which shows that the electrical installations have been checked to the required standard. The Manager and staff must undertake training on First Aid and the Manager must enrol on NVQ Level 4 in management. He must identify and put systems in place for monitoring the quality of care provided at the Home. Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 6 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. Maple House DS0000020051.V293313.R01.S.doc Version 5.1 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 Maple House DS0000020051.V293313.R01.S.doc Version 5.1 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 the following standard(s): 2 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Prospective residents’ needs were being fully assessed before admission. EVIDENCE: Full assessments and care plans were in place for the two existing service users at the unannounced inspection in May 2005. There has been no change to the resident group since that time. Maple House DS0000020051.V293313.R01.S.doc Version 5.1 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 the following standard(s): 6,7 & 9 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents’ health and welfare needs were not fully reflected in their care plans. Residents made decisions about their lives with assistance, as needed, and were being supported to take risks as part of an independent lifestyle. EVIDENCE: There was a generally good set of care plans and associated risk assessments relating to the two residents. Each care plan had an associated Implementation Sheet and Evaluation Sheet – the latter being designed to review care plans at least every six months, the Manager said. However, there had been no care plan review since April 2004 and the care plans did not reflect a number of current needs, and forms of behaviour, that had changed over two years. There was one particular form of challenging behaviour, exhibited by both residents, that was not being adequately recorded in either of the two care plans. It was not recorded at all in one care plan and, in the other, the relevant care plan was dated April 2004 and had not been reviewed. In this care plan there was no reference to any referral to a health professional and none to subsequent action taken (See Standard 19 in this report). There Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 10 had been no formal care plan review meeting - normally initiated by Social Services - for several years, regarding one resident. Both care plans examined mention limitations on the resident’s unsupervised movements outside the Home. The Manager stated that full discussion with, and agreement by, external professionals had taken place with regard to this Policy but there was no record, with signatures, to support this. The Manager and Deputy Manager stated that both residents choose which local pub to go to. They also choose which activities they get involved in and their going to bed times and rising times at weekends. Only on weekday mornings is there an expectation to rise in sufficient time to catch the transport to their respective day services. Examples of residents’ responsible risk taking were given by the Manager. One resident cycles every Wednesday with the local cycling club and takes a responsible attitude to using gardening tools in the garden. Both residents use all kitchen facilities and risk assessments were in place to reflect this. Maple House DS0000020051.V293313.R01.S.doc Version 5.1 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 the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were taking part in valued and fulfilling activities and were part of the local community. They were involved in appropriate personal relationships and their rights and responsibilities were being respected and recognised. Residents were being offered a healthy diet and enjoyed their meals. EVIDENCE: Both residents were attending day services five days a week. One resident was involved in a varied range of services that reflected his interests and was chosen by him. He was being paid for two day’s a week conservation work and this reflected his particular enjoyment of outside activities, the Manager said. This resident eagerly produced photographs of his conservation work, during this inspection. The other resident was attending a more traditional day service provision. The Manager spoke of elements of this being fulfilling - for example, five-aside football and being the caller at a weekly bingo session – as evidenced by the resident’s positive recall of these activities. During this inspection, this resident said of his day service: “I like it there”. Care plans Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 12 contained regular recording of these two residents’ social activities, including holidays. One resident is in a local ‘pool’ team and the Manager explained that he was “an active and successful” player. The other resident is a member of a local cycling club during the Summer, on Wednesday nights, and attends a ‘disco’ during the Winter months. He enthusiastically produced photographs and certificates, regarding his cycling, and said, “I like cycling”. Additionally, he goes to a social club for people with learning disabilities once a week. Both residents enjoy ‘Karaoke’ held at a local pub, the Manager said. One resident confirmed this by saying, “I like Karaoke and going to the pub”. One resident has a particular friend who he sees every day at his day service provision. The Manager spoke of the potential benefits to the resident of extending this relationship to the care home but this has not transpired, for no lack of encouragement from the Manager. This resident has no contact with his family but the other resident has contact with his mother and sister at one of his day service outlets. During this inspection he produced a photo album of his family. He also has a particular friend who he sees at day services. Both residents are well known to local people. The Manager explained that one resident will wash up after a meal and enjoys keeping the house tidy. He has a key to his bedroom door and keeps it locked at most times. He explained, during this inspection, that, “I like doing jobs around the house”. The other resident shows no interest in domestic activities other than cleaning his own bedroom once a week and making his own breakfast. Both residents have full access to all parts of the Home other than each other’s bedrooms and the private accommodation belonging to the Manager and his wife. A good range of meals were described on the Home’s 6-week rolling menu. A range of food was stored in the larder. Freezer levels were low due to a recent power cut while the Manager and residents had been on holiday. Both residents said the food was “alright here”. Maple House DS0000020051.V293313.R01.S.doc Version 5.1 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 the following standard(s): 18,19 & 20 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were receiving personal support in the way they preferred and required and their health needs were being met. EVIDENCE: The Manager explained that the residents had lived at the Home for several years and well knew their personal routines – seldom needing prompting or guidance on day to day matters. For instance, they choose their own clothes to wear each day. Guidance was needed when out clothes shopping though. One resident sometimes needed prompting to shave. The Manager provided evidence that the residents were being encouraged to be as independent as possible. There was documentary evidence of residents receiving medical checks and of medical appointments being kept. The Manager described the two residents as being in “rude health”. One resident’s diabetes was well controlled by his diet and was on no medication for his condition. There was recorded evidence of his weight being monitored in the past but there was no need now, the Manager explained. The other resident had been provided with speech therapy in the past but none for the last five years. The Manager said that he was not Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 14 being kept informed by Social Services who had referred both residents for specialist health input relating to an aspect of their behaviour. Neither resident was in receipt of medication. The Manager spoke of plans to provide a locked medicine cabinet as a prospective new resident receives medication. The Manager and Deputy Manager said they were planning to undertake a training course in dealing with medication, over the next six months. The Manager spoke of having a Medication Administration Record (MAR) sheet ready to put in place. He described good practice regarding the proper administration of medicines. The Home’s medicine policies now include the administration of ‘homely remedies’. Maple House DS0000020051.V293313.R01.S.doc Version 5.1 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 the following standard(s): 22 & 23 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were able to access a clear complaints procedure. They were being protected from abuse. EVIDENCE: A well-worded complaints procedure was displayed in the entrance hall although it still referred to the National Care Standards Commission (NCSC). There was no record of complaints received – the Manager said there had never been any complaints. There was a discussion of what forms a complaint may take and how complaints should be recorded. One resident stated, during this inspection, that he was, “happy here” and, later, he was heard to be singing from his bedroom. Certificates were seen to support the Manager’s statement that he and the Deputy Manager had attended a half-day training course on Adult Protection run by a private company. He also had a training CD Rom from Derbyshire County Council (DCC) and a DCC Policy and Procedures document. The Manager showed awareness of good practice in this area. Both residents’ financial records were examined and were cross-referenced to monies held. They were satisfactory. The Deputy Manager said that she checks balances on these records at each transaction. The Home’s ‘whistle blowing’ policy was examined. It did not address staff members’ potential fears of retribution and still referred to the NCSC. Maple House DS0000020051.V293313.R01.S.doc Version 5.1 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 the following standard(s): 24 & 30 Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service. Residents were living in a homely environment that still had some long outstanding matters to address. The Home was clean and hygienic. EVIDENCE: The Home was well decorated in most areas. Most of the work associated with extending the property to accommodate five residents had been completed. The hall, stairs and landing needed new carpet and the new bedrooms were still unfurnished. The new bathroom was complete except for a planned cupboard and easing of the fire door. There were still some building materials in the rear garden. The Home was clean. The Control of Infection policy was found to be satisfactory. There was no need for sluicing facilities as residents were fully continent. Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 17 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 & 35 Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service. Residents were being supported by a committed Manager and, in the main, were being protected by the Home’s recruitment procedures. Their needs were not being fully met by appropriately trained staff. EVIDENCE: The staff at the Home comprises the Manager, a nurse qualified in work with adults with a learning disability and with 16 years experience with this client group, and his wife as Deputy Manager. The latter’s experience of this client group is limited to her time spent at the Home, ie. since December 2005. The Manager and Deputy Manager displayed appropriate commitment to the residents and had a comfortable relationship with them. The Manager confirmed he was planning to appoint additional staff when new residents are admitted. The Manager was not aware of changes to Schedule 2 of the Regulations, which relate to the safe appointment of new staff. However, records showed that appropriate procedures had been followed with regard to the appointment of the Deputy Manager. The Home’s job application form did not reflect changes to Schedule 2 in that the dates of employment could be stated in Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 18 years, and so not highlight gaps in employment, and there was no space for ‘reasons for leaving a job’. The Manager had up-to-date guidelines for Induction and Foundation training, for new staff, under the Learning Disability Award Framework (LDAF). However, he was not intending to provide such training himself to the Deputy Manager and anticipated new members of staff. He had approached a local college for help but this had not been forthcoming. He said he would try again. Written confirmation was seen of a Fire training session booked for 9 August 2006 and a Health & Safety course on 12 July 2006. The Manager was advised that periodic viewing of an approved Fire Safety video would suffice following the Fire training in August. The Deputy Manager has a Basic Food Hygiene qualification - certificate seen – and the Manager showed evidence of payment for this training which he proposes to attend within the following three months. No First Aid training had been applied for. The need for mandatory training had been a matter outstanding from a number of previous inspections and was the subject of an immediate requirement notice at the last inspection. Although Moving & Handling training was not necessary, given the abilities of the two current residents, the Manager said he did intend to undertake this. Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 19 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 & 42 Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service. The Manager’s lack of a management qualification means that residents were not benefiting from a potentially better run Home. Residents could not be fully confident that their views were underpinning all self-monitoring by the Home. The Health and Safety of residents was generally being protected although one issue was outstanding. EVIDENCE: The Manager said he was unable, at present, to allocate time or money to gaining a National Vocational Qualification in Management at level 4. He gave an undertaking that he will apply when more residents are admitted. He confirmed that he was continuing to follow a programme of professional development in order to maintain his registration as a nurse. Discussion took place with the Manager and Deputy Manager as to what plans they had to introduce quality assurance systems into the Home. They said Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 20 they planned to put some questionnaires in place and were considering approaching the relevant day services providers requesting them to (i) enable the two residents to air their views on the Home and (ii) complete a questionnaire about services at the Home. The Home had no Annual Development Plan and the basis of this quality assurance tool was described to the Manager. There was evidence of good food hygiene practices in the kitchen. The Home had been using a Food Standards Agency record each day to record food temperatures daily, menu sheets and any problems occurring. Cleaning materials were being stored temporarily in an unlocked wall cupboard in the utility room. The Manager said there was no risk to residents but accepted that these materials did need to be made more secure. Product Data sheets, as required by the Control Of Substances Hazardous to Health (COSHH) Regulations, were in place. There was documentary evidence of Portable Appliance Tests (PAT) being undertaken in March 2006. The Manager stated that new electric wiring had only recently been installed and he would be applying for an Electrical Installation Certificate soon. Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 X X 2 X Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 22 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. 2. 3. Standard YA6 YA6 YA19 Regulation 15(2)(b) 15(1) 12(1)(b) Requirement Care plans must be regularly reviewed. Care plans must reflect how residents’ health and welfare needs are being met. Efforts must be made to find out what specialist health services are being provided to each resident. A record of these details must be maintained on care plans. Outstanding improvements to the environment, detailed in this report, must be undertaken. (Previous timescale was 31/7/05) The rear garden must be suitable and safe for residents to use. (Previous timescale was 31/7/05) The registered manager and staff must apply for training on first aid. (Previous timescale was 31/8/05) The registered manager must enrol on N.V.Q. Level 4 in management or equivalent. (Previous timescale was 31/12/05) The registered manager must DS0000020051.V293313.R01.S.doc Timescale for action 01/07/06 01/08/06 01/08/06 4. YA24 23(2)(d) 16(2)(c) 01/12/06 5. YA24 23 01/12/06 6. YA35 10 16/07/06 7. YA37 10 01/10/06 8. YA39 24 01/09/06 Page 23 Maple House Version 5.1 9. YA42 23 identify and put systems in place for monitoring the quality of care provided at the home. This requirement is outstanding from previous inspections. (Previous timescale was 30/09/05) The home must obtain a certificate which shows that the electrical installations have been checked to the required standard. (Previous timescale was 31/07/05) 01/08/06 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 YA6 Good Practice Recommendations Care plans should be internally reviewed monthly and a record made on the Evaluation Sheets. Formal review meetings, with external professionals, the resident and relatives as appropriate, should take place at least every six months. Multi-professional agreement to limitations imposed on residents’ unsupervised movements outside the Home should be recorded, with signatures. The Home’s complaints procedure should refer to the Commission for Social Care Inspection (CSCI). A system to record complaints received should be drawn up. The Home’s ‘whistle blowing’ policy should address staff members’ potential fears of retribution and should refer to the CSCI. The home’s recruitment policy and procedure and staff application form should be updated to cover all the required information and documents, which applies to a person working in the home. (This was a previous recommendation) The Manager should have in place an induction training programme that complies with the Learning Disability Award Framework. (This was a previous recommendation) The Manager should proceed to carry out the training programme detailed in the body of this report. DS0000020051.V293313.R01.S.doc Version 5.1 Page 24 2. 3. 4. 5. 6. YA7 YA22 YA22 YA23 YA34 7. 8. YA35 YA35 Maple House Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Maple House DS0000020051.V293313.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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