Inspection on 26/06/06 for Marlborough House

This inspection was carried out on 26th June 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marlborough House 01/07/08

Marlborough House 04/07/07

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 Marlborough House 54 Kirkley Cliff Road Lowestoft Suffolk NR33 0DF Lead Inspector Jane Offord Key Unannounced Inspection 26th June 2006 12.50 Marlborough House DS0000067388.V301186.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 Marlborough House DS0000067388.V301186.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. Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marlborough House Address 54 Kirkley Cliff Road Lowestoft Suffolk NR33 0DF 01502 572586 01502 584841 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) Amber Care (East Anglia) Ltd John Reid Clarkson Romayne Coleman Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (4) of places Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex aged 18-65 years who require care by reason of learning disability (not to exceed 12 persons). Four persons whose names were made known to the Commission for Social Care Inspection in July 2004 aged 65 years and over, who require care by reason of learning disability. The total number of service users accommodated must not exceed 12 persons. November 22nd. 2005. 3. Date of last inspection Brief Description of the Service: Marlborough House is a registered care home for twelve adults with learning disabilities with an age range from early twenties to over seventy years. It has recently changed ownership and is now owned by Amber Care (East Anglia) Ltd. A new manager has been appointed from within the existing staff team. Marlborough House is a large Victorian house situated on Kirkley Cliff in Lowestoft, opposite the promenade gardens and with views of the sea. There is access to the centre of Lowestoft with public transport. Accommodation is over three floors with a stair lift available between the ground floor and first floor. Communal rooms are situated on the ground floor with two large airy lounges facing the front of the house, large and small dining rooms are located off the kitchen and there is access to a small garden area from the dining rooms. One double room is on the ground floor and that has en-suite facilities. Other rooms are on the first and second floor, some have en-suite facilities and two have small kitchenettes. Other bathrooms and toilets are available for residents whose rooms do not have en-suite facilities. The fees at the home range from £331 to £618 per week depending on the funder and the level of care required by the resident. Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection looking at the core standards for Young Adults. It took place on a weekday between 12.50 and 15.50. The manager was available throughout the day to assist with the inspection process. A number of residents were in the home during the day because college had broken up for the summer or they did not access any day placements on that day. Two residents’ files, care plans and daily records were seen, as were two staff files. Medication administration records (MAR sheets), the policy folder, menus, staff rotas, fire equipment records and the minutes of staff meetings were all inspected. A tour of the home was conducted by the manager and time was spent with a number of residents and some staff members. On the day of inspection the home was clean and tidy. The décor looked attractive and the furnishings were appropriate for the resident group. The residents clearly felt relaxed in the environment and the interactions with staff and each other were friendly. What the service does well: What has improved since the last inspection? What they could do better: With the recent change of ownership a lot of the home’s paperwork needs updating. Some recruitment checks were not undertaken for one staff member. The medication policy needs to be adjusted to clarify the procedure to be used if a resident has difficulty swallowing medication. The duty rotas need to show all staff working in the home and the hours they work. Efforts should be made to identify residents’ final wishes and keep a record of them. Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 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. Marlborough House DS0000067388.V301186.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 Marlborough House DS0000067388.V301186.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use this service can expect to have their needs assessed prior to admission. EVIDENCE: The home has not admitted any new residents for over a year. Previous inspections have found that this standard is met. The Statement of Purpose, that has been updated by the new owners, states that prospective residents will have their needs assessed prior to admission, and if the home can meet their needs there will be a series of trial visits, extending in duration, until the resident is comfortable to move in. Marlborough House DS0000067388.V301186.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. People who use this service can expect to have a care plan that supports their chosen lifestyle and be supported to make decisions. EVIDENCE: The files and care plans of two residents were seen and showed a great deal of detail about the resident and how they wished to be supported. There was a note on one care plan that, ‘XXXX can sign their care plan but will not really understand the contents. Some time must be spent with them explaining it in simple language’. The care plan had information about the resident’s preferred daily routine from the time of waking to the bedtime drink and how many pillows they liked on their bed. It detailed the areas where the resident needed help and the areas of independence. There was a personal profile that included decision-making skills and memory. One file had notes that, ‘XXXX has limited road sense’, ‘XXXX has no sense of money value’, ‘XXXX has a mobile phone but will need support to use it and may need the programmes reset from time to time’. There was evidence that care plan interventions were reviewed and updated at the care team meetings (CTM) held monthly for each resident. Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 Page 10 One resident talked about a recent holiday they had had in Hastings. There was a post card displayed that they had sent the home while they were away. Another resident said their chosen holiday venue was Sheringham in Norfolk and they liked going every year. One resident’s file had an intervention to address a problem of unwanted weight loss. The GP and dietician had been consulted and a high fat, high calorie information sheet had been given to help give the resident the correct diet. Regular weight checks were recorded. Another resident who has been in the home a number of years is making plans to move to a flat with supported living. The manager said they had ‘outgrown residential living’. Staff have supported the resident to develop skills needed for independent living and the resident said they, ‘Can’t wait’, to move on. They have chosen carpets and paint for the new flat and bought some furniture. They have a meeting with the new care team later in the week. Marlborough House DS0000067388.V301186.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. People who use this service can expect to be offered meaningful activities and be encouraged to maintain contact with their family and friends. They can also expect to have a diet that they enjoy. EVIDENCE: Most of the residents access day services or college during the week. There are a number of different day services available and some residents use more than one in a week. One resident said they go to ‘Gateway’ twice a week, day care once a week and the ‘Drop-in’ once a week but on, ‘Mondays I stay here’. Another resident goes to John Turner House day centre each day Monday to Friday. Some residents also attended evening clubs too such as the Tuesday club. The files seen had records of the residents’ next of kin and their contact details. The daily records noted when a resident had seen family members or gone to spend time away from the home with parents or siblings. One file had a note that the resident had a special relationship with a person of the opposite sex and saw them at some clubs they both attended. Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 Page 12 One resident asked the manager to phone their mother about their forthcoming birthday celebrations. The manager phoned later and the resident spoke to their mother. They said their mother would pay for a disco evening to celebrate their birthday and the residents and staff were all welcome. They wanted to do Robbie Williams’ songs during the karaoke. As residents returned from their day activities general conversation took place. A lot of discussion was about the World Cup match that had taken place the previous day. Some gentle teasing took place about one resident’s crush on David Beckham. It was observed that the flag of St. George adorned the window in one of the lounges to support the England effort. As well as planned holidays the home offers outings from time to time. There was documentation about visits to the London Eye and a local Otter Trust. Also information about an in-house theatre company who would perform in the home, called ‘Frantic Theatre Company’. One of the staff said that there was a staff member rostered to work 10.00-17.00 each weekend and sometimes during the week. It was that person’s responsibility to take residents out to the shops, the beach, the pub or for a meal depending on what the residents wanted. They also organised indoor activities and games if residents chose not to go out or the weather was too bad. One resident follows the Muslim faith and their need to have running water for ritual washing had caused some flooding from their en-suite bath into the lounge below. Removing the bath and making a wet room of the area resolved the problem. The manager said staff are aware of the dietary needs of the resident and these are met. The resident does not attend a local mosque but the manager said they see a parent and visit London regularly and attend religious meetings there. The menus folder was seen and as well as menus it contained information about individual residents’ likes and dislikes for packed lunches and a series of photographs of common foods to help residents choose what they would like. The evening meal was to be gammon steaks with parsley sauce, potatoes and carrots or cheese and potato pie and salad followed by treacle sponge and custard. Lunch for residents who remained at the home during the day was a choice of toasties, sandwiches, flans, cheese and biscuits or sausage rolls. There was always available fresh fruit, yoghurts, cakes, ice cream and a choice of squashes, tea or coffee. A full English breakfast was available on Saturdays if it was pre-booked the day before. When residents returned from their day activities they helped themselves to a drink and a snack if they were able or a member of staff offered to make a drink for those who were less able or tired from their day out. Marlborough House DS0000067388.V301186.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21. People who use this service can expect to have their health care and emotional needs met but they cannot be assured that the present medication policy will protect them or that the service is aware of their final wishes. EVIDENCE: Both the residents’ files seen had contact details of any health professionals involved in the care of the resident, so there were GPs, dentists, social workers, chiropodists, opticians and dieticians listed. There were records of visits to or from any health care professional and the instructions given at the time of consultation. One file contained a quantity of published information about the symptoms and care of the resident’s uncommon genetic condition to help staff understand how to care for the resident. In the care plan under socialising for one resident there was an entry of, ‘A warm friendly person who likes the company of others’. It also noted that the resident likes football and tennis. One staff member said that the change of ownership had unsettled some of the residents who had expressed concerns about whether they would be able to continue living in the home and where their next meal was to come from. Staff had spent time individually and in groups reassuring them that the new owners would continue to support the same service. Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 Page 14 The home uses a monitored dosage system (MDS) that means medication comes from the local pharmacy in prepared blister packs. The MAR sheets were seen and were correctly completed with signatures or a code if medication was not given for some reason. Reasons for non-administration were recorded on the back of the MAR sheet together with the number of tablets given if a prescription offered a choice of dose. One prescription seen had instructions of, ‘to be given as directed’. Prescriptions must be unambiguous and need clarifying if the instructions are not clear and precise. The medication administration policy was inspected and offered comprehensive guidance on storage, ordering and disposal of medicines. The manager said the home never gave residents ‘homely’ remedies, which was why there was no section for that. One section that gave guidance on managing to administer medication if a resident found it difficult to swallow advised crushing tablets or putting them in food. Medication should not be altered or added to other substances without agreement from a medical practitioner. This section of the policy needs reviewing and a section on covert administration of medication added. One resident’s file did contain authorisation from their GP to crush tablets that they found difficult to swallow. Residents’ files seen did not have records of their final wishes. This was raised with the manager as some residents are now in their late sixties and early seventies. The manager said they were aware that it was an area that needed to be addressed and they already had templates of the paperwork on their computer to do it. One member of staff said they had not been at the home when a resident died but, judging from the way things were handled recently when a resident was seriously ill, they felt that a death would be handled sensitively and other residents would have any needs, as a result of the death, met by staff. Marlborough House DS0000067388.V301186.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. People who use this service can expect to have their concerns taken seriously and be protected from abuse. EVIDENCE: Neither CSCI nor the home have received a complaint since the last inspection. The complaints policy is robust and offers investigation of a complaint and written outcomes. It was displayed on a notice board in the hallway. The home has a copy of the guidelines issued by the Vulnerable Adult Protection Committee of Suffolk in June 2004. The home’s policy is crossreferenced to those guidelines but still refers to The Joint Inspection Team and that needs to be CSCI with contact details. Training records showed that staff had regular training about Protection of Vulnerable Adults and this was confirmed in discussion with staff. Marlborough House DS0000067388.V301186.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. People who use this service can expect to live in a comfortable homely environment that is clean. EVIDENCE: The house is a Victorian building with large windows and high ceilings in all the rooms. It feels spacious and airy. The manager conducted a tour of the home and everywhere was clean and tidy with attractive décor and furnishings. Residents’ rooms were personalised with pictures, posters, photographs and small ornaments and stuffed toys. The manager said that the residents’ key workers would help them with shopping and some had chosen their own bedding. Bathrooms and toilets seen were all clean with no unpleasant odours in the home on the day. Hand washing facilities were equipped with liquid soap and paper towels. The laundry area was seen and the manager confirmed that the washing machine has a sluicing programme. The infection control policy was inspected and offers robust guidance on reducing the risk of cross infection. Soiled laundry is taken to the laundry in alginate bags that go directly into the machine to reduce the handling of potentially infected linen. Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 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, 33, 34, 35, 36. People who use this service can expect to be supported by a staff team trained to meet their needs and properly supervised however they cannot be assured that all the recruitment checks will be done on new staff or that the duty rota reflects all the staff working in the home. EVIDENCE: The duty rotas were seen and explained by the manager. There are generally four carers rostered throughout the day and evening. Night time is covered by one waking and one sleeping member of staff. The home does not employ domestic or laundry staff, those duties are included in the carers role and the residents help within their capabilities. Amber Care (East Anglia) Ltd employs two maintenance people who visit the home a couple of times a week but are available by phone in the case of any urgent repairs. The rota did not show the manager’s hours. Two new staff files were seen. Both contained photocopied evidence that identification checks had been made. Each file had two references but only one had a POVA 1st and criminal records bureau (CRB) check. The manager said the other member of staff was from overseas and claimed they had never visited the UK before. It was explained that a check must still be undertaken and the manager agreed to process that immediately. The files contained documentary evidence that an induction programme covering the philosophy of care, fire, POVA, 1st aid and emergencies is done during the initial two days. Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 Page 18 The files had the job applications of the prospective staff members. One question asked for details of relevant work experience. The applicant had not done any care work before so the space was blank. The form had no other space for an employment history so for that applicant there was no record of their past work experience. The interview notes were seen but did not explore that area. The files had certificates for training that the staff member had undertaken and these included POVA, 1st aid, managing challenging behaviour, health and safety, food hygiene and medication administration training. Staff spoken with confirmed that they had regular training and updating. Staff also confirmed that they received regular supervision and the notes made during sessions were seen. The home has a staff team of fourteen carers plus a manager and deputy manager. The manager is undertaking both an NVQ level 4 and the registered managers’ award at present. Of the carers seven have achieved an NVQ level 2, three more are in the process of doing it and a further two staff are planning to start it in July 2006. Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 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, 40, 42. People who use this service can expect that it is managed to protect their health and safety and run by a competent manager however they cannot be assured that all the home’s documentation reflects the new ownership. EVIDENCE: The registered manager has been at the home in different posts since 1993. They were appointed manager in October 2005. As noted previously they are undertaking a level 4 NVQ and the registered managers award at the present time. Observation during the inspection showed that the residents relate well to the manager and feel comfortable to approach them for discussion. The kitchen was seen and looked clean and tidy. The cleaning schedules were completed and signed and dated. Records for the refrigerator and freezer temperatures showed they were functioning within safe limits for the storage of food. Records were kept of temperatures of food probed on delivery and of hot food prior to serving, all were within safe limits. There were risk assessments relating to food hygiene in place. Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 Page 20 Records were seen of checks to fire equipment. Fire extinguishers, fire alarms and a check for fire hazards are all looked at weekly. The emergency lighting is done annually and was last done a few days before the inspection on June 22nd. The manager said that the views of residents are sought with a formal questionnaire but the results of the most recent survey have been packed away with a number of other documents when the home changed ownership. The change of ownership has meant that a large number of documents need updating to reflect the new owners. The manager is aware of that and is addressing the task. Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 3 2 2 3 X 3 2 X 3 X Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NONE. 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. Standard YA20 YA20 Regulation 13 (2) 13 (2) Requirement All prescriptions must have unambiguous instructions for administration of the medication. The medication policy must give clear guidelines about the procedures to follow if a resident has difficulty swallowing tablets and include guidance on covert administration of medication. Efforts must be made to ascertain and record residents’ final wishes. The duty rota must reflect all the staff working in the home and the hours that are worked. The required checks must be undertaken on all prospective staff prior to employing them. Timescale for action 26/06/06 31/07/06 3. 4. 5. YA21 YA33 YA34 12 (3) 17 (2) Sch 4 (7) 19 (b) (i) Sch 2 30/09/06 26/06/06 26/06/06 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 YA40 Good Practice Recommendations All the home’s documentation should be reviewed to DS0000067388.V301186.R01.S.doc Version 5.2 Page 23 Marlborough House ensure that it reflects the new ownership. Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Marlborough House DS0000067388.V301186.R01.S.doc Version 5.2 Page 25 - 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!