Inspection on 14/06/06 for Hawthorns

This inspection was carried out on 14th June 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hawthorns 05/07/07

Hawthorns 15/01/07

Hawthorns 03/02/06

Hawthorns 23/05/05

Hawthorns 02/09/04

Hawthorns 06/05/04

Hawthorns 13/10/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Maytrees 2 Bushey Ground, Brize Norton Road Minster Lovell Witney Oxfordshire OX29 0SW Lead Inspector Lilian Mackay Unannounced Inspection 14th June 2006 10:00 Maytrees DS0000028948.V299855.R02.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 Maytrees DS0000028948.V299855.R02.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. Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maytrees Address 2 Bushey Ground, Brize Norton Road Minster Lovell Witney Oxfordshire OX29 0SW 01993 776336 01993 709056 princecres@aol.com 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) Meriden Homes Limited Miss Jacqueline Godwin Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 2006 Brief Description of the Service: The home is registered to provide care for up to six adults under 65 with a learning disability. The needs of residents have been described as mild to moderate learning disabilities and autistic spectrum disorder. The home is not registered to admit those requiring care mainly because of their physical disablement, dementia or mental disorder but strives to continue to care for those who become so, as long as it can continue to meet their needs. The home was considering the special needs of one client who has developed a dementia at this time. Residents’ mental health needs are secondary to their learning disability and these are met by the community mental health services. The fees for this service range from £1,500 to £3,000 weekly. Extras include toiletries, clothes and personal items. Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced key inspection, undertaken by two inspectors. The inspectors arrived at the service at 09.15 am and were in the service for five hours. The inspection could not take into account the normal detailed information to be provided by the service’s owner as this was not provided. It did take into account any information that the CSCI has received about the service since the last inspection. The residents living in this home are all aged under 65. The National Minimum Standards for Care Homes for Adults (18-65) have been used for the purpose of this inspection as they reflect the needs and lifestyle choices of those being supported in this home. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. To further inform the findings of the inspection the inspector asked residents and staff for their views and opinions of the service provided. The inspectors could not send surveys to social and healthcare professionals associated with the care home as their contact details were not supplied as requested prior to this inspection. The inspectors spoke with all six residents and three of the four members of staff on duty and examined staff and residents’ files and other records. The inspectors would like to thank the residents and staff for their assistance, hospitality and courtesy during this inspection. What the service does well: Residents’ needs are fully assessed before coming to live at the home. There is a key worker system in operation where the care of each resident is the responsibility of a named member of staff. Personal care plans are reviewed frequently. A range of appropriate activities is provided for residents. Two senior staff interview prospective members of staff. Employee of the month awards are identified. There has been continuity of management since 2002. Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Maytrees DS0000028948.V299855.R02.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 Maytrees DS0000028948.V299855.R02.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 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Every resident has a full assessment of his or her care needs prior to being admitted to the home. EVIDENCE: Full professional assessments of residents are undertaken and the home also carries out its own care needs assessments. A sample of care plans was examined and found to include a pre-admission assessment of care needs. The registered manager carries out all the home’s pre-admission assessments, and she encourages prospective residents to visit the home as many times as they like before coming to stay. Many of the residents come in on a short stay basis before committing to a long stay. Maytrees DS0000028948.V299855.R02.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. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a service tailored to the individual needs identified in personal care plans [PCPs]. The sample of care plans examined gave a very clear “picture” of the individual resident and their care needs, and very clear guidance for responding to behaviours. Daily records were completed and there was good evidence of clear incident reporting, of appropriate action being taken and of corrective action being implemented to limit a recurrence of the issue. Regular reviews of personal care plans are carried out and clearly documented. Risk assessments are carried out, reviewed and documented and these are effective in promoting residents’ independence. EVIDENCE: The PCPs seen reflected residents’ social needs well and gave staff clear guidance for responding to behaviours. Evidence was seen that these are reviewed three monthly, exceeding the frequency recommended by the National Minimum Standards. Managers, key workers and residents attend these reviews. Staff work positively with residents to promote their Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 10 independence. Where residents are experiencing disturbed sleep, sleep charts are used to monitor this. A sample of care plans was examined and each was found to include a preadmission assessment of care needs. Risk assessments are carried out and reviewed regularly. Dating these helps to identify when review is due. Residents’ access to their personal files has been recently risk assessed to ensure these are kept more securely. Maytrees DS0000028948.V299855.R02.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. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents participate in a range of developmental activities and are involved in local community life. Residents are given the opportunity to take part in a variety of activities and to pursue their own interests and lifestyle. They have appropriate personal and family relationships and are encouraged to accept responsibility in their daily lives. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. EVIDENCE: Staff are now recording when residents go out or participate in activities in the daily observation sheets. One daily observation sheet seen was noted to have particularly good recording of the social activities undertaken. Evidence was seen that residents are encouraged to pursue their own interests and hobbies. Residents have a TV, video player, music centre and pool table for their use. Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 12 Residents’ involvement in activities is regularly reviewed. Residents go away on holiday and attend a Saturday Club. Within the local community residents go to the pub for a drink, visit the fish and chip shop, celebrate birthdays, visit the hairdresser’s, attend college, go to the cinema, go swimming, go into Witney and do personal shopping. Report sheets for recording visitors to the home have not been completed recently. The Regulations require such a record to be kept. These are kept in the fire log. The record of visitors to the home must be easily accessible to visitors and identifiable as such. Residents have a communal pay phone for making calls. Residents’ personal and social relationships are identified in their PCPs. Staff recognise the importance of family relationships and make efforts to re-establish contact where this has broken down. Where family relationships exist these are encouraged and residents supported to make home visits. Residents take part in the housekeeping rota to practise domestic skills such as laying tables, preparing meals and washing up. Within the care plans examined was evidence of the daily social and recreational activities that residents had taken part in. These included visits to the shops, the pub and attending college to pursue their studies. The menu plans seen featured residents’ meal choices and residents were seen preparing the mid-day meal. Maytrees DS0000028948.V299855.R02.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. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s key worker system ensures consistency for residents. Residents’ physical and emotional health needs are met through a range of communitybased services. Competent staff administer medication. EVIDENCE: There are currently no handrails in either the bathroom or the shower room. This is acknowledged and consideration is going to be given to the provision of these as one resident is now becoming frailer physically. It is recommended that an occupational therapy assessment be carried out of these areas for this purpose. There are regular multi disciplinary team meetings (MDT) held in the home and there is easy access to a psychiatrist, psychologist, and the local police. There is good documentary evidence of MDT meetings and any changes that need to be implemented. The medication system was examined with the registered manager and overall found to be in good order. It was noted that the instructions for administration on the medication administration record were handwritten and that the person Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 14 who had written them had not countersigned these. This is not good practice and could lead to errors being made in giving the correct dosage. Homely remedies such as throat lozenges and lotions are given but there is no list of approved remedies that is agreed and signed by the GP. This is contrary to the Royal Pharmaceutical Society’s guidelines for the administration and control of medicines in care homes. One of the medication administration records showed that a medication had only been given twice a day when the instructions say 3 times daily. The registered manager explained that this had been agreed by the GP as the resident was being affected by the side effects of the medicine. There was no record of the change being agreed or discussed with the GP. This is not good practice and any changes in the dosage of medicine must be documented and signed by the GP. None of the present group of residents takes responsibility for administering their own medication. The pharmacist visits the home on a regular basis and offers training for staff. The registered manager has recently undertaken training to enable her to assess staff competence in administering medication. This is commendable. Maytrees DS0000028948.V299855.R02.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. The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The complaints procedure is compliant with the Regulations and is accessible. The registered manager ensures that all staff have an understanding of issues around adult protection. EVIDENCE: The complaints procedure has been amended since the last inspection to indicate that the CSCI is the regulating body. It is now compliant with the Regulations. One complainant has contacted the CSCI with information concerning a complaint made to the service since the last inspection. No residents raised any issues with the inspectors when they spoke to them. The home has a copy of the Oxfordshire Multi agency guidelines for the protection of vulnerable adults. Staff receive training in the protection of vulnerable adults and the registered manager said that this is included in the induction training for new staff and an update is planned in the near future. A recent allegation against a staff member revealed that management failed to report an allegation to the adult protection officer for Oxfordshire County Council Social and Community Services and the client’s placing authority and did not agree the procedure to investigate the allegation through a strategy meeting with the learning disability team. Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 16 However, the inspector noted that the allegation appeared to have been very thoroughly investigated internally. It is recommended that management review their internal complaints policy and procedure and their protection and prevention of abuse policy. Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 17 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. The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Improvements to the environment must be made more promptly. The home was tidy and fresh smelling at this time. EVIDENCE: At the last inspection on 03.02.06 the skirting board in the bathroom was coming loose, the dining room walls and ceiling were marked and in need of redecoration, the lounge ceiling was stained by a recent leak, dining tables were wobbly and had torn table cloths, sharp earth pins under the shower room sink needed boxing in, the coving in the shower room was coming away from the wall, the walls there needed redecoration and the shower cubicle edging needed repair where it was water stained. These recommended improvements have not been made and so these are now being made a statutory requirement, as this standard of internal decoration is unacceptable. A start had been made on redecorating the walls in the corridor. Fire extinguishers were not all either fitted to the wall or held in a stand designed for this purpose. Fire doors were wedged open at this time, compromising the home’s fire precautions. This practice must be discontinued immediately and Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 18 the advice of the fire service sought with regard to the fitting of suitable devices such as Dorguards or electromagnetic devices, The areas visited were tidy and fresh smelling. Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 19 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. The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst there is a strong commitment to NVQ training, the required ratio has not been achieved within the timescale given. The number and skill mix of staff on duty is good. The recruitment procedure is poor, and training and development is not planned or recorded in a clear way to ensure that all staff receive necessary training. EVIDENCE: The staff roster examined showed that sufficient numbers of staff and an adequate skill mix are on duty at all times. The registered manager has supernumerary time in order to carry out her management duties. A sample of three staff files was examined including the most recent recruit who had been working at the home for 5 months. One file was incomplete and not in accordance with the Regulations. One staff file did not have two written references and one staff member who had started in January 2006 had yet to be given a contract. Similar failings in documentation were seen at the last Unannounced Inspection in February 2006, and a requirement was made at that time, when there was no photograph of the employee, only one reference, no Criminal Records Bureau (CRB) check or Protection of Vulnerable Adults (POVA) First check. The other two staff files were in accordance with the Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 20 Regulations. Concerns about the home’s recruitment practices were highlighted in the last inspection report and no improvement has been noted. Within the staff files was a document for staff reviews that stated “bi-monthly”, however these appear to be carried out on an annual basis. Staff training is in progress and the registered manager is in contact with a training provider who will provide ongoing training such a fire safety, and protection of vulnerable adults. A number of staff are progressing with the National Vocational Qualification level 2 in care and at the time of this inspection a visiting National Vocational Qualification assessor was present in the home working with one of the staff. The registered manager said that six of the staff are registered on the programme and that the latest recruit is due to start next month. Once these staff are through the programme the target of 50 of all care staff being trained will be exceeded. A requirement to provide training in infection control and mental disorder was made at the last inspection but this has not been implemented. The manager showed the inspectors a new training package that she is proposing to implement on the subject of equality and diversity. A recent incident in the home led to reviewing current practice in Control and Restraint (CNR) and the manager showed the inspectors the documents about the latest guidelines in physical intervention that have now been put in place. The training provided appears ad hoc and it is recommended that a staff training and development plan be implemented, and a matrix developed which shows the individual staff training provided. Staff did control and restraint and breakaway training in Spring 2005 and refresher Training was being planned. As some residents exhibit challenging behaviour it is required that all staff undertake such training. Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 21 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. The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager and the deputy manager are undergoing appropriate training. For the most part the home’s record keeping and policies and procedures safeguard residents’ health, safety and welfare. The care provision and staff teamwork are good but the supporting management systems are poor. EVIDENCE: The manager is very knowledgeable about the residents and their conditions and they are her focus. She has good communication with the relevant professionals. To improve communication with other professionals the manager should be given e-mail. Management did not participate fully in the inspection process as they did not complete either the preinspection questionnaire or the self-assessment tool sent to them by the CSCI, neither did they distribute surveys to residents and relatives or visitors. Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 22 Both the manager and the deputy manager are working towards an NVQ 4 and Registered Managers Award. Records required by regulation were examined by the inspector and found to be up to date and complete. The registered manager explained that there had been a recent incident when the office and all documentation had been attacked by a resident and that she was in the process of trying to put this back in place, and reordering the office in the process. The residents’ records were the priority and these were found to be in good order. There was little evidence of quality assurance systems being in place. The registered provider makes regular monthly visits to the home but records of these visits were not available for inspection as required by Regulation 26. Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 X 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 3 X 3 X 2 X X 3 X Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 24 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 YA15 Regulation 17(2) Schedule 4 Requirement Keep an easily accessible record of visitors to the home which is easily identifiable as such. This is an outstanding requirement with the original timescale set as 03/02/06 Staff to sign handwritten entries in the medication administration records. This is an outstanding requirement with the original timescale set as 03/04/06 Return medications to the pharmacist for destruction immediately they become out of date. Make a list of the homely remedies used and have this signed and approved by both the doctor and the pharmacist. This is an outstanding requirement with the original timescale set as 03/04/06 Record any changes agreed or discussed with the GP and have these signed by the GP. Review the internal complaints DS0000028948.V299855.R02.S.doc Timescale for action 14/07/06 2. YA20 13(2) 14/07/06 14/07/06 31/08/06 14/07/06 30/09/06 Page 25 3. Maytrees YA23 13(6) & Version 5.2 22(1) 4. YA24 23(2)(b) 5. YA24 13(4)(a) 6. YA34 19(4)(b) 7. YA35 18(1)(c) 8. 9. 10. YA35 YA36 YA39 18(1)(c) 18(2) 26(2) policy and procedure and their protection and prevention of abuse policy. Make good the following - the loose skirting board in the bathroom, the marked dining room walls and ceiling, the stain on the lounge ceiling, wobbly dining tables, torn table cloths, and improve the décor in the shower room and make it safe. Discontinue wedging fire doors and take the advice of the fire service regarding the fitting of suitable devices to these. Keep all the documentation on staff required by the Regulations. This is an outstanding requirement with the original timescale set as 31/08/05 Provide training in infection control and mental disorder. Outstanding requirement from the last inspection. This is an outstanding requirement with the original timescale set as 31/10/05 All staff to attend training on restraint and breakaway training. Supervise staff quarterly. The registered provider/the manager must ensure that records of monthly visits to the home are available for inspection at the home. 30/09/06 14/07/06 14/07/06 31/12/06 31/10/06 14/07/06 14/07/06 Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA18 YA22 YA35 YA37 YA41 Good Practice Recommendations Request an occupational therapy assessment of the areas identified. Review the internal complaints policy and procedure and the protection and prevention of abuse policy. Ensure at least 50 of care staff are trained to at least NVQ level 2 or equivalent. Give the manager e-mail facilities to improve communication. Review all policies and procedures every three years. Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South, Cowley Oxford OX4 2SU 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 Maytrees DS0000028948.V299855.R02.S.doc Version 5.2 Page 28 - 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!