Inspection on 31/08/06 for Melbourne House

This inspection was carried out on 31st August 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Melbourne House 17/05/10

Melbourne House 20/07/09

Melbourne House 06/08/07

Melbourne House 09/05/06

Melbourne House 10/10/05

Melbourne House 22/04/05

Melbourne House 24/01/05

Melbourne House 03/08/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Melbourne House Chapel Road Foxhole St Austell Cornwall PL26 7UG Lead Inspector Philippa Cutting Key Unannounced Inspection 31st August 2006 09:30 Melbourne House DS0000009192.V307337.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 Melbourne House DS0000009192.V307337.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. Melbourne House DS0000009192.V307337.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Melbourne House Address Chapel Road Foxhole St Austell Cornwall PL26 7UG 01726 823853 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 Janet Rosemary Brewer Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Melbourne House DS0000009192.V307337.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 13 adults with a learning disability (LD) Total number of service users not to exceed a maximum of 13 Date of last inspection 9th May 2006 Brief Description of the Service: Melbourne House is a detached property currently registered to provide care and accommodation for up to 13 people with a learning disability. There are currently seven service users in home, all of whom have lived there for an average of 20 years (although not with the same ownership during that time). A condition that the numbers should be reduced to 12 adults with a learning disability, as the home was one over numbers, will be put in place following this inspection. Accommodation is provided on the ground and first floor, which are linked by a staircase. There are communal areas on the ground floor - a sitting room, dining room and small sun lounge. Externally there are two small patios, 18’ x 12’ and 15’ x 9’, a greenhouse and at the top of the garden a long building. In the past this has been used as a workshop where people went during the day. It is not currently fit for use. The premises are not suitable for any one with mobility problems as there are steps throughout, both inside and out. The external access would be very difficult to ramp with the correct gradient. Melbourne House DS0000009192.V307337.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 key inspection undertaken by two inspectors. Records were inspected, the premises toured and service users and staff interviewed. The registered person called into the home during the inspection and stayed to answer queries and discuss the home with the inspectors. At the previous inspection the views of the local College that the service users attend and a day centre were sought. They were closed for the summer break so this was not possible on this occasion. After the previous inspection, all families were contacted to seek their views about their relatives’ care but only one person responded. That was positive. As four service users and staff were out for the day the conversations that took place were limited as a view of all service users in the home. The atmosphere felt more positive than on previous visits and the service users who had remained at the house seemed happy and relaxed with the member of staff on duty. Staff in the home currently undertake the domestic tasks as well as caring ones. This may work satisfactorily for now but if proposed building work commences the position may need to be reviewed in order for the home to remain in a satisfactory state. Fees in the home range from £324.00 – 362.50 per week. What the service does well: What has improved since the last inspection? What they could do better: The redecoration of empty bedrooms needs to be speeded up so that service users can have single rooms. Melbourne House DS0000009192.V307337.R01.S.doc Version 5.2 Page 6 Evidence of increased activity within the home for service users who are spending a day at home needs to be provided. This could include domestic tasks such as helping with shopping. A stable staff team needs to be built up – there has been quite a high turnover of staff in the last few years. 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. Melbourne House DS0000009192.V307337.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 Melbourne House DS0000009192.V307337.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 As there have been no new admissions since the present registered provider took over, these standards were not assessed apart from reading the revised statement of purpose. This is satisfactory. EVIDENCE: There are currently seven service users who have lived at Melbourne House for between 18 to 22 years. Their ages range from 47 to 80 years. The registered provider has reviewed and revised the statement of purpose but to date there have been no new admissions to the home. The registered person is aware of the pre admission assessment procedures detailed in standard 2. Melbourne House DS0000009192.V307337.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 The outcome group is judged as adequate. Service users have not had much opportunity throughout their early lives to be involved in making decisions for themselves. Most spent formative years in a time when they were told what to do rather than choose for themselves. Consequently they have come to rely on the staff to continue doing this for them. EVIDENCE: Care plans were in place for each service user. These included timetables of planned activities for each person (see next section). The majority of service users are not very proactive in suggesting changes or decisions about their lives as most have been ‘in care’ for long periods of their lives and have not had the opportunity to develop this aspect of independence. Where someone has suggested a change (re hairstyles for example) they have been helped to achieve this. All service users have been reviewed by their social worker. In response to certain questions some said they would need to ask a relative before commenting or responding. Melbourne House DS0000009192.V307337.R01.S.doc Version 5.2 Page 10 Risk assessments are in place; in several cases these relate to a person’s ability to go out alone, mostly within the village, as there are road safety issues to be considered. The home should consider completing a full ‘activities of daily living’ assessment on each person so that there is dated evidence of each person’s ability to wash, dress, perform basic hygiene functions etc with the level of prompting or help needed. At present the care plans say that X needs help to wash & dress or that Y got up etc. They do not indicate whether help is provided through habit or the need for speed to get ready to go out in the mornings. It would be valuable as a guide to each person’s abilities to know how much assistance is needed or whether people who look after their own personal care do so to a satisfactory standard. It would also act as a marker for future progress as some service users are showing signs of age related disabilities. To this end a discussion occurred with the registered person regarding the continued review of service users’ needs and welfare that should include reference to minimum standards for adults with a learning disability and minimum standards for older persons. Melbourne House DS0000009192.V307337.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): 11,12,13,14,15,16,17 The outcome for this group of standards was judged as adequate. Whilst the service users have more opportunities to engage in outside activities than they did six years ago, when the home changed hands, the home will need to ensure that enforced changes in activities does not mean that service users become more home based. There are problems in encouraging service users to be more proactive in making choices, as they have not had the life experience to help them do this. EVIDENCE: Each service user has a daily plan for activities. Until recently service users have attended college where there have been opportunities to pursue various courses. The funding for this has now been reduced so the home is seeking alternatives. Some younger people have work placements that they attend; others go to day centres. Local social or friendship clubs are nearby. People can attend the Horizon clubs on weekday evenings. On the day of this inspection four service users & a member of staff had gone on a day trip to Torquay with the local social club, leaving three people at Melbourne House with a member of staff. Opportunities for leisure activities in Melbourne House DS0000009192.V307337.R01.S.doc Version 5.2 Page 12 the home need to be actively encouraged. Staff said that a number of the service users like to colour or knit and some play simple games. The television was on during the major part of the day with one person saying that he was watching ‘this’. He was not able to describe what ‘this’ was but appeared to like the movement and voices. Favourite videos were noted. Two of the service users who had remained in the house helped prepare vegetables and clear away after lunch. One said she often helped and appeared to like this. The other person is still active and also enjoys gardening, using the greenhouse to grow cucumbers and tomatoes etc. The inspectors noted that one person seemed unable or very reluctant to respond when asked about various interests and activities, turning instead to another service user to answer on her behalf. It would be good to ensure that this person has opportunities to speak for herself but it can be difficult to change habits and set patterns. The registered provider pointed out that although the activities arranged for some might be limited, until she became the owner there were very few outside contacts at all. She felt that the service users’ horizons had been broaden since her input. As service users do help in the home, consideration should be given to including them in further aspects of the home, such as shopping trips etc. Dietary requirements were discussed. This has been a topic of concern on previous inspections following comments from past members of staff. The service users have their main meal in the evenings when everyone is at home together. Lunch tends to be more of a snack such as soup and sandwiches. Fresh fruit and vegetables were seen to be available. All service users are weighed regularly. The recorded weights showed that most were fairly stable with minor fluctuations. The registered provider said she had concerns about one service user who had a cardiac condition. The registered provider felt it was important that this person’s weight should be kept under control. She said that warning the service user about the problem of getting ‘fat’ was not intended to be abusive but it was using terms that the service user would understand rather than euphemistic words like ‘overweight’ or ‘too heavy’. One person is encouraged to drink Enlive – a nutritional supplement. Melbourne House DS0000009192.V307337.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 outcome for these standards was generally good. The physical care needs of service users are noted and addressed by supportive medical staff and carers. Medication is undertaken carefully with training for staff organised. More input from the services that deal with learning difficulties could be broached. EVIDENCE: The physical health of the service users is monitored by the local health centre, who, the staff report was supportive and helpful. Reference is made to professionals depending on need. A service user discussed his skin condition and an appointment for continued review with a Dermatologist was noted. Other records showed service users using the local surgery for health appointments. Medication reviews have occurred and the dietician and psychiatrist are consulted as required. There does not appear to be much contact with the adult service for learning disability. As the age profile of service users is increasing this might be a good avenue to pursue to ensure that the service users receive all the help available. The importance of referring to both the minimum standards for adults with a learning disability and minimum standards for older persons was again reinforced. Melbourne House DS0000009192.V307337.R01.S.doc Version 5.2 Page 14 Medication is undertaken on behalf of all service users via a monitored dose system. This was seen to be kept securely with the medication administration record sheets being completed. Care staff are enrolled on a safe handling of medicines course. The member of staff on duty demonstrated the methods that she had been taught when administering medication. It was satisfactory. The way that one person’s Day Centre insists that lunchtime medication is dispensed was discussed. The home is complying but an opinion will be sought from the Commission’s pharmaceutical advisor. Melbourne House DS0000009192.V307337.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): 23 The inspection looked at service users’ finances in some detail. The outcome was satisfactory. Information on PoVA & Whistle blowing has been sought for staff. This needs to be continued as an on going process for any new staff. EVIDENCE: The service users require support with the organisation, storage and decision making of their personal finances and valuables. All service users are financed by Cornwall Social Services. A schedule of the financial arrangements detailing the local authority and service user contribution towards fees was seen on individual files. The registered person is an appointee for all service users and a detailed record is maintained of these contributions, personal allowances and Disability Living Allowance. The DLA (Mobility Allowance) is used to finance the home’s minibus and provide for the transport needs of service users. The home’s policy and service user guide provides details of this agreement. The personal allowance records were inspected and three separate entries of service user spending were seen to cross reference with the records of activities and outings. These records also record details of service user spending on personal items. Various items were chosen at random and the receipts for these items were available and the shoes, duvet and watch were seen in the home. An individual account, held on behalf of a service user, was checked and found to be accurately maintained. The registered person stated that the savings held by these processes would fund a holiday for service users. Melbourne House DS0000009192.V307337.R01.S.doc Version 5.2 Page 16 A requirement is made for the registered person to maintain an inventory of furniture belonging to service users and records of valuables deposited for safekeeping or returned- reference regulation 17: schedule 4-9 and 4-10. Melbourne House DS0000009192.V307337.R01.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): 24,25,26,27,28,30 This outcome group is judged as adequate. The service users’ rooms meet their requirements with the exception of one. There are arrangements in hand to deal with this but these have become protracted. Other parts of the home are sorely in need of attention but are not being used until renovation has taken place. Communal areas are satisfactory although people have asked for new furniture in the sitting room. The kitchen and utility areas have been refitted and present no problems. The service users at Melbourne House have simple expectations and rarely complain about their surroundings. EVIDENCE: Melbourne House has been home to the service users for on average 20 years. They have single rooms with one exception although the inspector was told at the previous inspection that this was going to change and everyone would be given single rooms as, the inspector understood, one service user who shares had expressed a wish for a single room. This has not yet happened, as redecoration needs to take place first. Melbourne House DS0000009192.V307337.R01.S.doc Version 5.2 Page 18 Service users’ rooms were clean apart from some high level dusting on light shades and wardrobe tops. Beds were properly made and rooms left tidy. There is an odour problem in one room that has been addressed but persists. One room was an exception to the general condition. The curtain was half off the rail, torn paper noted in places on the wall and a wardrobe door was missing. This room is little changed from the inspection made on May 9th 2006 when the same damage was seen. The registered provider said that the intention was for this service user to move to another room that was going to be prepared for him. The delay had been caused by the service user’s family who had wished to buy furniture for the service user themselves. There had been a problem in getting the furniture, which was flat packed. It had now arrived but its assembly was not yet complete. The upstairs area that has been identified as office space is still in a stripped state awaiting redecoration. The kitchen has been renewed. This and the back lobby & laundry area were clean and tidy. The rear portion of the house is in a poor state but the registered provider said she was expecting a builder to visit the following day with a view to assessing the practicalities of installing new drains and pipe work so that a much needed new bathroom could be made and renovation of this part of the house undertaken. The present bathrooms (one on the first floor & one on the ground floor) are now shabby and in need of renewal. The inspectors noted that there were bolts on final exit fire doors by the laundry and the ground floor bathroom. It should be removed and advice sought from either Fire Safety officer at the Brigade or the home’s fire contractor about suitable replacements. Externally the garden was tidy and there were tables & chairs provided where people had been able to sit outside in the fine weather. From the rear of the property the outline of the roof and skylights suggest that these need regular checks to ensure their soundness. The site of the home means that there are steps at both the rear & front of the property and to the first floor internally. It would not be suitable for anyone with mobility difficulties. Melbourne House DS0000009192.V307337.R01.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 outcome for the standards that were inspected were judged as satisfactory on the whole. Some further information needs to be held on staffing details but evidence of various good training options that have been initiated was seen. EVIDENCE: A discussion occurred with the support worker on duty regarding the induction process, routines and procedures at the home. Support workers are also responsible for cooking and cleaning duties at the home. There is a minimum of two carers on duty by day and a waking night carer is supported by an on call system. The registered provider is on the staff rota from 5pm and provides evening support at the home and the on call support at night should staff and service users require assistance. There has been some turnover of staff and the registered provider assisted in providing records regarding staff recruitment, induction and training for inspection. There was evidence of some induction records being completed and advice is given to introduce the appropriate induction procedures for new staff with reference to www.skillsforcare.com. Individual staff profiles were inspected and appropriate training opportunities have been completed in NVQ level 2 and above, first aid, protection of vulnerable adults procedures and food hygiene. Support workers are currently Melbourne House DS0000009192.V307337.R01.S.doc Version 5.2 Page 20 involved in a six month distance learning course regarding the management and safe handling of medication. The recruitment records inspected showed that support workers complete an application form; PoVA First check and appropriate references were received. A requirement is made for the registered person to complete a new enhanced CRB check for support workers seeking employment at the home and maintain records of this process. A requirement is also made to maintain the records for all staff in compliance with regulation 17: schedule 4-6. Melbourne House DS0000009192.V307337.R01.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): 37,38,39,41,42 Overall the outcome for these standards were judged to be adequate. The registered person is appropriately qualified but now needs to consider how the home can be moved forward given the environmental limitations and the need for quality audits. EVIDENCE: The registered provider holds her Registered Manager ‘s Award. She owns two homes in Cornwall. The inspector discussed the problems that have arisen, following the employment of two managers in the last two years, with the registered provider, in particular the adverse comments and allegations made by them. It was not possible to determine how or why this happened but the inspectors agreed that on the evidence presented at this inspection the service provided was now adequate and not poor. The service users who were in the home at the time of this inspection appeared to be happy but it is not in their nature to complain. There were no Melbourne House DS0000009192.V307337.R01.S.doc Version 5.2 Page 22 adverse comments about the fact that they had not gone on the outing with the others; they were either accepting of the decision that they would not go (due to being poor travellers or having continence problems) or did not seem very interested. Their comments did not suggest that they felt penalised or ‘hard done by’ nor did they appear to be nervous when the registered provider was present. Records required by statute were inspected and were judged to be in order. There is going to be an increasing importance placed on a self-audit of quality by individual homes. This is an area that needs consideration. The registered person must ensure that the service users are protected from any adverse effects if the proposed building work is carried out and that all the necessary clearances are obtained from the Building Control Officer at Restormel Borough Council prior to and at the completion of any works. Melbourne House DS0000009192.V307337.R01.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 3 2 X 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 X 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 2 12 2 13 3 14 2 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 2 2 X 3 3 X Melbourne House DS0000009192.V307337.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 17 (2) Schedule 4.9 & 4.10 Requirement An inventory of furniture belonging to service users and records of valuables deposited for safekeeping or returned must be complied and maintained by the registered provider. Bolts currently fixed to final exit doors must be removed and alternative arrangements for securing those doors sought from the Fire Safety Officer or the home’s fire contractor. The registered person shall provide in rooms occupied by service users adequate furniture, bedding & other furnishings, including curtains and floor coverings, and equipment suitable to the needs of service users and screens where necessary. This requirement is repeated from the previous inspection. The registered provider must provide the Commission with a time scale for the renovation of the bedrooms within the home. The documentation and DS0000009192.V307337.R01.S.doc Timescale for action 31/10/06 2. YA24 23(4) 31/10/06 3. YA26 16(2)(c) 31/10/06 4. YA34 7,8,9 31/10/06 Page 25 Melbourne House Version 5.2 Schedule 2 information detailed in Schedule 2 must be obtained for all staff. 5. YA39 Criminal Records Bureau checks must be sought for all new staff irrespective of whether they hold a current valid one from a previous employment. 24 The registered person shall (1)(b)24(2) establish and maintain a system for improving the quality of care provided at the care home and The registered person shall supply to the Commission with a report in respect of improving the quality of care. This requirement is repeated from the previous inspection. The registered provider must provide the Commission with details of how a quality audit system will be introduced. 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations A full record of a service user’s functional ability in regard to self care should be prepared, dated and kept under periodic revision so that it gives guidance as to the level of help each person requires. Contact & support should be sought from the adult learning disability team to ensure that the service users are able to obtain all the help and benefit which they may need. 2. YA18 Melbourne House DS0000009192.V307337.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Melbourne House DS0000009192.V307337.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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