Inspection on 05/07/06 for Mclaren House

This inspection was carried out on 5th July 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mclaren House 29/05/08

Mclaren House 14/05/07

Mclaren House 16/01/06

Mclaren House 30/08/05

Mclaren House 09/02/05

Mclaren House 15/09/04

Mclaren House 18/03/04

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

CARE HOME ADULTS 18-65 Mclaren House 93 Bratt Street West Bromwich West Midlands B70 8SH Lead Inspector Mrs Mandy Beck Key Unannounced Inspection 4th July 2006 09:00 Mclaren House DS0000004784.V302009.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 Mclaren House DS0000004784.V302009.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. Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mclaren House Address 93 Bratt Street West Bromwich West Midlands B70 8SH 0121 500 5430 0121 500 5430 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) Mrs Paulette Shirley June Phillips Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: McLaren House is registered to provide residential care for 9 people aged between 18 and 65 who are experiencing mental ill health. The aim of the home is to provide a rehabilitation service to enable its users to return to living independently in the community. There are however no set limits and this may be over a long period of time. The home is a three storey mid-terraced property situated close to West Bromwich town centre with easy access to all local amenities and transport networks. There is parking space for 2 cars at the front of the property and gardens at the rear. Accommodation is provided over three floors. On the ground floor there is an office, staff toilet, one single bedroom, lounge, dining room, conservatory (smoking room), kitchen, laundry and toilet with a shower. On the first floor there are four single bedrooms and a bathroom with toilet. The second floor has two double bedrooms both with en-suite toilet and shower facilities. The Home currently charges a minimum of £590. per week for each service user. Prices may vary depending upon the needs of the service users. Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector from the commission for social care inspection. The inspection began at 09:00hrs and concluded at 16:00hrs. Information and judgements given throughout this report are base upon information given to the inspector by the Registered manager, staff and service users. The Registered manager also provided information to the Commission for Social Care Inspection in the home pre inspection questionnaire. Service user files were seen as part of the case tracking methodology. In addition to this staff files were also seen to ensure that the home continues to protect service users with effective and robust systems of recruitment and staff training. A tour of the home was also undertaken. The inspector would like to thank the service users, staff and the registered manager for their hospitality throughout the inspection. What the service does well: What has improved since the last inspection? Since the last inspection the home now has a registered manager in place. There has been some progress in meeting some of the outstanding requirements from the previous inspection and this was pleasing to see. Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 6 Service users now have care plans that are designed around their individual needs and risk assessments have also been improved for each service user, it was pleasing to see service user involvement in this process. The home has continued to have it’s physical environment improved with installation of a new kitchen, refitted shower room on the ground floor and the two en suite showerooms on the second floor. 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. Mclaren House DS0000004784.V302009.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 Mclaren House DS0000004784.V302009.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): 1,2,5 Prospective service users do not have up to date information about the service they need to make an informed choice. All service users can be assured that their individual needs will be assessed. Written contract or statement of conditions does not inform service users of all their conditions of residency. EVIDENCE: The statement of purpose and the service user guide for the home is in need of review to ensure that both documents meet the required minimum standard. The home has had no new admissions since the last inspection. There is an outstanding requirement that the admission procedure is reviewed this has not been completed. Service users files that were looked at all contained an assessment of their needs; there was also evidence of the multi agency assessment documentation from social workers and community mental health nurses. It is from these assessments that the manager works with the service user to develop their individual service user plan. Some of the service users had a contract of terms in their file that they had signed in some cases, the contract does not detail all of the fees charged and what service users are expected to pay for. For example service users are not given a seven day holiday as part of their basic contract price this should be indicated in the contract. Mclaren House DS0000004784.V302009.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 Service users have an individual plan that details their required needs, they are encouraged to make decisions about their lives and the assistance they require. The home supports all of the service users to live an independent lifestyle. EVIDENCE: Each service user has an individual plan of care. These have been developed since the last inspection and the manager has worked hard to include the service users in planning the care they receive. The plans are written in language that service users understand and are person centred in their approach, whilst they still require some fine tuning it was pleasing to see the progress the manager has made. Service users are clearly involved in the process of planning their care but the manager must now consider ways of demonstrating this and service user involvement within the review process. Service users are encouraged to make choices about the lives they lead and the activities they take part in. For those service users who need outside help there is information available for them to be able to contact independent advocacy groups if they wished. Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 10 All but one of the service users manage their own money and have good levels of support from staff should they need it. On the day of the inspection all the service users had been to the post office to collect their personal allowance and were seen to be giving clear instructions to care staff about they wanted to do with their money. The home keeps records of all monies incoming and outgoing with receipts as proof of transactions. Both service users and staff sign when money changes hands, further protecting service users. Mclaren House DS0000004784.V302009.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, The overall outcome for this group of standards was judged to be good. Service users are encouraged to take part in occupational activities and to retain their links with the community. Relationships with friends and families are supported and service users can feel assured that they will be treated with respect and given support with the decisions they make. All service users are encouraged to eat a healthy diet and to prepare it themselves where possible EVIDENCE: All of the service users at McClaren House attend day centres throughout the week where they have an opportunity to meet with other people. Trips to the nearby town centre often take place as service users will go on their own or accompanied by a care worker. Service users are encouraged to be as independent as they can be, service users were seen to be collecting their own shopping, ordering taxis to take them out, and preparing shopping lists for their menus. Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 12 Families and friends are welcomed into the home, and there is no limit on the times for visiting. All service users have the opportunity to receive visitors in private should they wish to do so. Daily routines are generally flexible to suit service user needs however there must be some structure as it is part of the recovery programme for the service users. All service users with the exception of one has a key to the front door and a key for their own rooms. All mail is received unopened and is not opened unless service users request staff do this for them. Service users have unrestricted access to all parts of the home and were seen making cups of tea and preparing meals during the inspection. The manager and staff usually prepare a weekly menu for service users every Friday. In addition to this staff sit down with individual service users to help them plan for their week ahead as they are encouraged to do as much for themselves as possible in the kitchen. This includes meal planning, preparing the shopping lists and cooking the food. Service users demonstrated a good understanding of the health and safety requirements whilst working in the kitchen and the importance of hand washing to minimise the risk of infection. Meals are generally served in the dining room which has recently been decorated and is currently awaiting the arrival of new pictures which will help to give the room a more relaxed and inviting feel to it. Mclaren House DS0000004784.V302009.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 The overall outcome for this group of standards was judged to be adequate. Service users can be assured that their health needs will be addressed promptly and generally care will be given in a way they prefer and require. Medication practices within the home are designed to safeguard service users. EVIDENCE: The manager and staff have worked well to develop the individual care plans for each service user. There needs to be some fine tuning to ensure that all needs are met in a way that service users prefer and require. For instance indicating whether or not service users prefer female or male assistance when personal care is provided. Service users are encouraged to get up and go to bed when they are ready to do so subject to restrictions they have agreed in their own individual plan. There was evidence to demonstrate that service users have access to a range of specialist community services should they require them, these included the mental health teams and the dentist. All but one of the service users administer their own medication. All medicines are kept centrally and administration is witnessed by the care staff. Once a week care staff and service users sit down and as care staff observe, they dispense their medication into a medidose pack for the forthcoming week, once Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 14 this is completed the medication is stored in the secure medication cupboard. Records are kept of all medicines received, administered and leaving the home this ensure that there is no mishandling of medication. The home also receives regular pharmacist visits, there are some requirements outstanding from the last audit which require the managers attention. Care staff have received some training from the pharmacist but at present no member of staff has taken part in accredited training of safe handling of medicines. Mclaren House DS0000004784.V302009.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 The overall outcome for this group of standards was judged to be adequate. Service users can feel that their views will be listened to and acted upon. The policy and procedures within the home need to be reviewed in order to offer comprehensive protection from abuse, neglect or self harm EVIDENCE: The home has received no complaints since the last inspection. It was therefore not possible to audit the complaints log or the outcome of investigations. Service users were quite clear about whom they would talk to if they were unhappy, “June always listens to me if I want to say something”. The complaints policy needs to be reviewed to ensure that the name of the Commission for Social Care Inspection is included and reference to NCSC is removed. The complaints policy is displayed in the reception area next to the visitors book. The Protection of Vulnerable Adults Policy also requires reviewing to include National and Local authority guidance, so that staff can be clear of their responsibilities in reported suspected abuse. The manager has arranged for all staff to receive training in adult abuse awareness and this is due to take place in August. Mclaren House DS0000004784.V302009.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 The overall outcome for this group of standards was judged to be good. The home has been refurbished and provides a homely comfortable environment for all service users. The home is clean and hygienic but staff would benefit from infection control training. EVIDENCE: A tour of the premises was undertaken, the manager pointed out all of the new decorating and refurbishment that has taken place since the last inspection. On the day of the inspection new fire doors were being fitted this will provide extra safeguards to service users in the event of a fire. On the ground floor the home has benefited from a new fitted and well equipped kitchen. Two toilets have been converted into a combined toilet and shower room, this is very popular with the service users who make good use of it. On the second floor the two double bedrooms have had their en suite facilities upgraded to a high standard. Service users spoken to indicated that they were pleased with the changes although they are now anxious for the new carpets and chairs for the lounge to arrive. Two service users bedrooms were viewed, with their permission, and were seen to be pleasantly decorated and personalised to their own tastes. Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 17 The home was clean and tidy and there were no offensive odours throughout the day. Due to the design of the home the laundry is situated next to the kitchen, the manager has procedures in place to ensure that no contaminated laundry is bought through the kitchen unless it is in a sealed bag. There are also procedures in place for the safe handling of washing and all service users clothing and bedding is done separately. The laundry was kept clean and tidy. Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 The overall outcome for this group of standards is judged to be adequate. Staff do not have clear job descriptions to guide them, staff training must be improved. The home’s recruitment and selection policies do not safeguard service users. EVIDENCE: The staff group remains stable, all of the staff spoken to indicated how much they enjoyed working at Mclaren house. It was evident that care staff have a good relationship with the service users and a clear understanding of their individual needs. The home has achieved it’s target of 50 of care staff having achieved their NVQ level2 in care, there are plans for the remaining staff to complete theirs in the near future. Other staff training has been arranged such as safe handling of medications, and adult abuse awareness. The manager must consider ways of keeping track of who has completed what training and provide each member of staff a learning and training plan based upon their individual training needs as well as the staff team as a whole. Serious concerns were expressed about the recruitment processes within the home. Staff files lack the required information. In one case necessary PoVA/CRB disclosure had not been completed since 2004. This was an outstanding requirement from the previous inspection and must be addressed urgently to ensure that service users continue to be protected. Other files seen lacked appropriate references, the manager must satisfy herself that Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 19 references are authenticated and at one reference must relate to the person’s last period of employment which involved working with vulnerable adults. All gaps in employment history are explained with a satisfactory written explanation for any gaps. None of the staff files seen contained a job description that details care workers roles and responsibilities whilst working at Mclaren House. The manager is currently working with staff to ensure that they have access to supervision and support this is still in it’s infancy and requires further development to ensure that staff receive supervision at least six times a year. Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The overall outcome for this group of standards was judged to be adequate. Service users benefit from a well run home and that their views will be considered when developing the home. The welfare and safety of service users is generally promoted and protected. EVIDENCE: June Philips is now the registered manager of Mclaren House. She is qualified and competent to run the home. She has completed her NVQ level 4 and her Registered Managers Award. Ms Philips would benefit from having a job description that outlines her overall responsibilities to the home in respect of reviewing policies and procedures, ensuring that the aims and objectives of the home are being met and the home’s budget. Ms Philips would also benefit from regular supervision in order to maintain her skills and to identify her own training and development needs. Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 21 The quality assurance system has been improved since the last inspection; service user questionnaires were seen, there were regular audits completed for the environment and for safe working practices for staff. To ensure that the home’s quality assurance system is based upon a cycle of planning – review – action the manager must collate this information and publish an action plan that demonstrates how the home will address the issues raised. Other information about how the service is meeting it’s aims and objectives should be sought from relatives/visitors, and stakeholders in the community such as community mental health nurses and GP’s. The safe working practices within the home are generally promoted, all of the relevant certificates to demonstrate electrical systems, gas boilers and central heating servicing and legionella risk assessments were all seen, this list is not conclusive. The manager must ensure that all staff receive mandatory training as required, some of the staff files seen indicated that training in infection control, food hygiene, health and safety were out of date. It was recommended that the manager produce a training matrix that shows when staff training is due rather than relying upon information held in staff files. Accidents are recorded but as with the service user questionnaires require the information be collated to identify trends and possible action plans to reduce accidents within the home. Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 2 33 X 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 2 X X 2 x Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4,6 Requirement The homes Statement of Purpose and service user guide needs to include all the information required under the minimum standards. This is an outstanding requirement from 9th February 2005. Comprehensive assessments must be completed for all perspective service users before admission. Assessment information including a current Care Programme Approach (CPA) care plan and assessment must be received before admission. This is an outstanding requirement from 30th August 2005. The home must be able to confirm in writing that they are able to meet service users needs before admission. This is an outstanding requirement from 30th August 2005. Timescale for action 30/09/06 2 YA2 14,15 30/09/06 3 YA3 14,15 30/09/06 Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 24 4 YA4 14 The home must update its admission procedure in line with current practices and minimum standards. This is an outstanding requirement from 30th August 2005. Statements of terms and conditions or contracts must meet the minimum standards and be completed with all service users. The use of advocates should be used if necessary. This is an outstanding requirement from 9th February 2005. Individual care plans must include all details of how care is to be delivered and what actions to be taken circumstances change Service users must have an annual 7-day holiday included as part of the basic contract price. This is an outstanding requirement from 9th February 2005. 30/09/06 5 YA5 17 30/09/06 6 YA6 14,15 30/09/06 7 YA14 12(3), 16(2)(m) 30/09/06 8 YA23 12,37 The homes whistle blowing and 30/09/06 adult protection procedures must be updated. Staff must sign to state they have read and understood the procedures. This is an outstanding requirement from 9th February 2005. The homes vulnerable adults policy must be updated to include information from National and Local authority and give clear guidance to staff of their responsibilities in reporting suspected abuse DS0000004784.V302009.R01.S.doc 9 YA23 12,37 30/09/06 Mclaren House Version 5.2 Page 25 All staff must be issued with a copy of the new policy. The registered manager must obtain a copy of the “No Secrets” guidance from the Department of Health. All must staff, including the registered manager must have a job description that defines their roles and responsibilities All staff must have a police record check (CRB & POVA). This is an outstanding requirement from 30th August 2005. The registered provider/manager must ensure that all employees have the required two written references. Where applicable a reference relating to the person’s last period of employment, which involved work with vulnerable adults The registered provider/manager must be able to satisfy themselves of the authenticity of those references. The registered provider/manager must ensure that a full employment history is obtained with satisfactory written explanation of any gaps. All needs identified through individual training plans must be met. Copies of qualifications must be kept on file. This is an outstanding requirement from 30th August 2005. DS0000004784.V302009.R01.S.doc 10 YA31 19 30/08/06 11 YA34 19 15/07/06 12 YA34 19 (c ) schd 2 15/07/06 13 YA35 19 30/09/06 Mclaren House Version 5.2 Page 26 14 YA36 19 Supervision must be provided at least 6 times a year with an annual appraisal. Part met. This is an outstanding requirement from 30th August 2005. Quality assurance procedures need to be implemented and systems used to obtain and record the opinions of the service users, friends, relatives, visitors and others. Part Met This is an outstanding requirement from 9th February 2005. The registered provider must complete required Regulation 26 visits as required All policies as listed in Appendix 2 of the standards are implemented and reviewed. These should be signed and dated by the manager and by all staff once they have read and understood them. This is an outstanding requirement from 9th February 2005. Decanted cleaning materials must be labelled in line with legal requirements. The loose brickwork on the rear first floor building must be examined. The fire risk assessment must be updated as required by the last fire officer’s report. 30/09/06 .15 YA39 17,24,36 30/09/06 16 .17 YA39 YA40 24,26 12,17,18 30/09/06 30/09/06 18 YA42 9,10,12,13 30/09/06 19 YA42 12 All staff must receive required 30/09/06 mandatory training in infection control, food hygiene, health and safety and safe moving and handling. DS0000004784.V302009.R01.S.doc Version 5.2 Page 27 Mclaren House 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 Refer to Standard YA19 YA32 Good Practice Recommendations The home should make sure the method for tracking health care needs is used accurately and consistently. It is recommended that the manager produces a training matrix that clearly demonstrates what training staff have received and when refresher training is due. Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Mclaren House DS0000004784.V302009.R01.S.doc Version 5.2 Page 29 - 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!