Inspection on 31/07/06 for The New House

This inspection was carried out on 31st 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The New House 03/03/09

The New House 04/02/08

The New House 11/01/06

The New House 30/06/05

The New House 13/10/04

The New House 15/04/04

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

CARE HOME ADULTS 18-65 New House, The 17 Stonerwood Avenue Hall Green Birmingham West Midlands B28 OAX Lead Inspector Brenda O`Neill Unannounced Inspection 31st July 2006 09:40 New House, The DS0000017084.V304604.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 New House, The DS0000017084.V304604.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. New House, The DS0000017084.V304604.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New House, The Address 17 Stonerwood Avenue Hall Green Birmingham West Midlands B28 OAX 0121 778 6391 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 Mary McNamara Mrs Mary McNamara Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places New House, The DS0000017084.V304604.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Three service users, by reason of mental disorder (3MD) exc. LD and DE aged under 65 years The two current service users who were under 65 at time of admission can continue to be cared for in this home for such a time that their needs can be met. The home must ensure assessment is undertaken by a qualified person to ascertain bathing facilities in the home meet the needs of service users. The home must reassess needs regularly to ensure that increasing physical needs are recognised and met. 11th January 2006 Date of last inspection Brief Description of the Service: The New House is a detached two-storey house that was constructed in 1991 for the purpose of providing residential care to three adults for reasons of mental illness. Accommodation consists of three single bedrooms, one of which has en suite facilities and there is a separate bathroom on the first floor. Ground floor accommodation includes a lounge, kitchen/dining room, conservatory, with a lobby off the kitchen providing access to a toilet and sleep-in room /lounge for visitors and staff. There is a small, well-maintained garden to the rear of the property with off road parking at the front. The home offers ongoing support to residents with mental health needs, residents are actively involved in the day-to-day running of the home. The fees at the home are £326.44 per week. New House, The DS0000017084.V304604.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out by one inspector over one day in July 2006. During the inspection a tour of the premises was carried out, all residents files and staff training records were sampled as well as other care and health and safety documentation. The inspector spoke with all three residents, one member of staff and the manager. Prior to the inspection a completed pre inspection questionnaire had been forwarded to the CSCI that gave a variety of information about the home. What the service does well: What has improved since the last inspection? There was ongoing review of the residents’ needs by the staff at the home and recently ‘step by step’ goals had been introduced where it had been discussed with the residents what they would like to achieve and progress towards these was being monitored. Risk assessments for the residents had been further developed since the last inspection and included such things as bedrooms, use of the shower, making New House, The DS0000017084.V304604.R02.S.doc Version 5.2 Page 6 tea, washing up, other resident issues and crossing the road when out with details of how these risks were to be minimised. Further improvements were required. A new medication cabinet had been purchased enabling the medication to be stored safely. Medication sheets were being signed at the time the medication was administered. The complaints procedure had been amended and included the contact details for the CSCI office in Birmingham as recommended at the last inspection. Staff files had been completed with the addition of an up to date photograph. The health and safety of the residents had been improved with the fire alarm being tested weekly and the fridge and freezer temperatures being taken on a daily basis. Some areas of the home had been redecorated making it brighter for the residents. 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. New House, The DS0000017084.V304604.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 New House, The DS0000017084.V304604.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, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Resident’s individual aspirations and needs were assessed. Residents had individual contracts so that they are aware of the terms and conditions of their stay at the home. EVIDENCE: The current resident group had lived at the home for a considerable amount of time. Previous inspections had found that prior to admission appropriate assessments had taken place. At the end of 2005 two of the residents had been reassessed to establish if they would be suitable to move to supported living accommodation but concluded that this was not a viable option. There was ongoing review of the residents’ needs by the staff at the home and recently ‘step by step’ goals had been introduced where it had been discussed with the residents what they would like to achieve and progress towards these was being monitored. Residents files included individual contracts that detailed the terms and conditions of their stay at the home. These included the fees to be paid and were signed and dated. New House, The DS0000017084.V304604.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The care planning system in the home was good but the manager needed to ensure the plans were regularly updated to reflect the current needs of the residents and that any assistance required was specified. Further improvements were needed to individual risk assessments to ensure all risks were minimised. Residents made decisions about their lives on an ongoing basis. EVIDENCE: All three residents’ files were sampled. All included care plans that had been based on the outcomes of the National Minimum Standards and covered areas such as personal care, mental health, social needs and health care needs. Some of the areas covered in the care plans included sufficient information so that staff knew how to support the individual however others did not. For example, one resident needed some assistance with personal care but this was not specifically detailed in the care plan and none of the care plans detailed how staff would now if the residents’ mental health was relapsing. The staff member spoken with knew the residents well and how to meet their needs and New House, The DS0000017084.V304604.R02.S.doc Version 5.2 Page 10 recognise deterioration in their mental health but this may not apply to all staff and needed to be documented for any new staff. The plans were being reviewed regularly however some of the details in the reviews needed to be updated into the care plans to ensure they were current, for example, one resident was no longer having assistance when showering. This decision had been made following a recent risk assessment and discussion with the individual but had not been updated in the care plan. Resident made decisions about their daily lives on an ongoing basis including, what they do, where they go, what they eat, what they wear and who they have contact with. One of the residents chose not to attend a club on the afternoon of the inspection and this was not an issue. There was evidence in the daily records of one resident refusing to go out with visitors as she wanted to have lunch in the home and staff respected this. One of the residents had decided she would like contact with people from her country of origin as she enjoyed their music and dancing and staff were pursuing this for her. Two of the residents continued to manage their own financial affairs, collect their own money from the post office and pay their own fees. Risk assessments for the residents had been further developed since the last inspection and included such things as bedrooms, use of the shower, making tea, washing up, other resident issues and crossing the road when out. However several areas of the residents had no risk assessments, for example, use of public transport, their vulnerability when out alone, when would they be deemed missing when going out independently and so on. These issues were discussed with the manager and staff member and further risk assessments were to be discussed with the residents. New House, The DS0000017084.V304604.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, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. There were good arrangements in place to ensure the residents living in the home experienced meaningful lives. Residents were very satisfied with the catering arrangements at the home. EVIDENCE: All the residents appeared to have fulfilling lives and were encouraged and enabled to be as active and participate in as many activities as they were able. Two of the residents were of retirement age and the other was not employed. Organised activities that the residents attended included luncheon clubs, ballroom dancing, day centre, bingo afternoon and keep fit. The residents daily records evidenced that they regularly go shopping, go out for walks, have pub meals and go to the library. Two of the residents were able to go out independently and use public transport. One of the residents often went out to visit family and friends independently. There was also evidence of frequent visitors to the home. One of the residents spoke to the inspector about the friends she had at the various venues she attended. New House, The DS0000017084.V304604.R02.S.doc Version 5.2 Page 12 When at home residents helped with general tasks around the house, for example, tidying their rooms, washing up, meal preparation and laundry. One of the residents spent a lot of time in the garden when not out and about and helped with the gardening. Another resident told the inspector he enjoyed watching old films and listening to music in his bedroom. As stated earlier staff were trying to identify contact with people from one of the residents country of origin as she enjoyed their music and dancing. The rights and responsibilities of the residents were recognised, for example, all had been offered keys to their rooms but chose not to have them, their rights to privacy were detailed in their care plans, evidence of their rights to refuse visitors were seen in the daily records, residents had access to all areas of the home apart from other residents bedrooms unless invited. The residents were aware of the rules in relation to smoking in the home. The residents were very happy with the catering arrangements at the home. There was a menu in place but if residents wanted something different it was provided. The residents helped with meal preparation and clearing up. Residents were observed preparing and making drinks for themselves and could help themselves to food items from the kitchen if they wished. The manager needed to ensure that records of the food being served to the residents were kept to evidence that they received a nutritious diet, choices were available and also that the medical diet needed by one of the residents was being catered for. New House, The DS0000017084.V304604.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The residents’ needs in relation to health and personal care were being met. The medication administration system was well managed and safe. EVIDENCE: Residents were generally self caring in relation to personal hygiene with only one needing minimal assistance. Residents’ preferences and abilities in relation to personal care were detailed in their care plans, for example, bath or shower. The documentation in the home evidenced that the residents’ needs in relation to their physical and mental health were being met. There was evidence of visits to the G.P., the dentist, regular blood tests where necessary, hospital appointments being kept, one resident had been visited by the audiologist and in the past advice had been sought from the speech and language therapist. There was evidence of regular check ups by psychiatrists and that where necessary the appropriate professionals have been contacted when there had been any deterioration in the mental health of the residents. Residents were also being weighed on a regular basis. New House, The DS0000017084.V304604.R02.S.doc Version 5.2 Page 14 Medication continued to be administered via a 28 day monitored dosage system and this was very well managed. Medication was acknowledged when received into the home and signed for when administered, this was not always being done at the last inspection, copies of prescriptions were being kept so it was clear what the doctor had prescribed. At the time of the last inspection the storage for medication was not appropriate this had been rectified and a specific drug cabinet had been purchased. All staff were administering medication and had received some training from Boots. The manager and one other staff member had completed their accredited training and the other staff were undertaking this. New House, The DS0000017084.V304604.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The residents were satisfied that any issues they raised would be addressed. There were adequate arrangements in place to ensure that residents were protected from abuse. EVIDENCE: The home had not received any complaints and none had been lodged with the CSCI. There was an appropriate complaints procedure on display in the home which had been amended since the last inspection and included details of the CSCI office in Birmingham. The residents spoken with appeared happy that if any issues did arise they could tell the manager and were confident they would be addressed. There were updated policies and procedures on site in relation to the recognition of abuse and the reporting procedures. It was strongly recommended that the manager obtained a copy of the multi agency guidelines for adult protection to run alongside their own procedures. Staff had undertaken training in adult protection and the prevention of abuse. New House, The DS0000017084.V304604.R02.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, 25, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home offered residents a homely and comfortable environment that met their individual needs. EVIDENCE: The home was well maintained, generally safe and accessible. It was noted that the carpet on one of the stairs was fraying and was a potential tripping hazard. The manager stated that the carpet was to be replaced but would ensure it was safe until then. Residents were satisfied with their bedrooms and all were appropriately personalised. Residents were able to keys for their rooms but chose not to. It was strongly recommended that the types of locks fitted to the bedroom doors were changed to a type that staff could always access in the event of an emergency. Residents were able to leave keys in the doors of the present locks when they were inside their rooms meaning staff would not be able to enter if necessary. It was also recommended that a lockable facility was made available for the residents in their bedrooms in case they wanted to lock away any personal effects or money. New House, The DS0000017084.V304604.R02.S.doc Version 5.2 Page 17 Residents were able to choose if they had a bath or a shower. One resident has an en suite shower room, however they said that they prefer to have a bath. Another resident said they prefer to have a shower and use the other residents en suite when they are not in there. The Manager said that the resident who prefers a shower was given the option of moving to this bedroom when it became vacant but chose not to. This arrangement had been discussed with the residents at previous inspections and they were happy with it. Prior to the last inspection the manager had sought advise from an occupational therapist in relation to aids and adaptations in the home and as a result a grab rail had been fitted to the side of the bath and two inside the shower. There was adequate communal space in the home with a lounge, kitchen diner, small conservatory and an additional small lounge area if residents wanted some additional private space, this also doubled up as the sleeping in room. All the communal areas were clean, fresh and nicely furnished and some had recently been repainted. The home was found to be clean and hygienic. Since the last inspection the fridge and freezer temperatures were being taken on a daily basis to ensure foods were kept a appropriate temperatures. New House, The DS0000017084.V304604.R02.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Staffing levels were appropriate for the needs of the residents. Staff had received training in safe working practices. The recruitment procedures were robust and safe guarded the residents. EVIDENCE: There had been no changes to the staff team since the last inspection which comprised of the manager, three permanent care staff and one bank staff member. The staffing levels appeared to meet the needs of the residents as they were fairly independent. One member of staff slept in at the home each night, these duties were shared between the staff team. Recruitment procedures were checked at the last inspection and found to be robust and as there had been no new staff were not checked at this visit. The only requirement made was that there must be a recent photograph included in staff records and this had been met. Since the last inspection the manager had completed NVQ level 4 and one of the care staff NVQ level 3, another member of staff was undertaking her NVQ level 2 which will give the home the required 50 when she has completed. Staff had undertaken training in COSHH, fire procedures, adult protection, food New House, The DS0000017084.V304604.R02.S.doc Version 5.2 Page 19 hygiene, first aid and manual handling. Infection control and medication training was ongoing at the time of the inspection. It was strongly recommended to the manager that she explored the availability of training specifically related to mental health needs. New House, The DS0000017084.V304604.R02.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The manager ensured the smooth running of the home in a competent manner. The home needed a quality assurance system in place based on seeking the views of the residents with a view to continuously improving the service. Health and safety of the staff and residents was generally well managed. EVIDENCE: The manager had completed her NVQ level 4 since the last inspection. She had many years of managing the home and had a very good knowledge of the residents’ needs and the running of a residential home. The manager and staff had continued to work hard to meet the requirements made from the last two inspections and several improvements had been made over this period of time. There were some informal ways of monitoring the quality of the service offered in the home, for example, health and safety checks, residents meetings, New House, The DS0000017084.V304604.R02.S.doc Version 5.2 Page 21 occasional staff meetings and resident questionnaires. However the manager and staff member spoken with were aware that the home needed to have a quality assurance system in place based on seeking the views of the residents with a view to continuous improvement and had been researching this on the Internet. The health and safety of the residents and staff were generally well managed. Staff had received training in safe working practices. The in house checks on the fire system were up to date and these were being done on a weekly basis as required at the last inspection. Every month a member of staff talked to the residents about what to do in the event of a fire and there was a fire risk assessment however this was in need of review. There were also general premises risk assessments in place for such things as food hygiene, COSHH storage and smoking. There was evidence on site of the up to date checks on the electrical wiring and the portable electrical appliances. The service on the gas equipment was overdue as of April 2006. The manager informed the inspector this was due to be done 12 August 2006. A valid certificate of employers liability insurance was displayed in the home. New House, The DS0000017084.V304604.R02.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 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 1 X X 2 X New House, The DS0000017084.V304604.R02.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 YA6 Regulation 15(1) Requirement Care plans must: • • • Be updated as the needs of the residents change. Specify what type of assistance that is required by the residents. Include details of how staff would recognise a relapse in their mental health. 01/09/06 Timescale for action 01/10/06 2. YA9 13(4)(a-c) 3. YA17 17(2) Sch4(13) 4. YA24 13(4)(c) Risk assessments must be in place for all activities that residents participate in. These must include specific measures taken to reduce the risk and must be regularly reviewed. (Previous timescales of 31/01/06, 31/08/05 and 28/02/06 partially met.) Records of the food being served to the residents must be kept in sufficient detail to evidence that the diet is nutritious and varied and that any special diets are catered for. The fraying stair carpet must be made safe. DS0000017084.V304604.R02.S.doc 01/09/06 14/08/06 New House, The Version 5.2 Page 24 5. 6. YA32 YA39 18(1)(a) 7. 8. YA42 YA42 50 of care staff must be qualified to NVQ level 2 or the equivalent. 24(1)(2)(3) A formal quality assurance system must be in place. This must include the views of residents and their representatives. (Previous time scale of 31/05/06 not met) 23(2)(c) There must be evidence on site of an up to date service of the gas equipment. 23(4)(c)(v) The fire risk assessment must be reviewed and updated if necessary. 01/12/06 01/12/06 14/08/06 01/09/06 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. 2. 3. 4. Refer to Standard YA23 YA25 YA25 YA35 Good Practice Recommendations It is strongly recommended that the manager obtains a copy of the multi agency guidelines for adult protection. It is recommended that the locks on the bedroom doors are of a type that can be opened by staff in an emergency. It is strongly recommended that residents have a lockable facility in their bedroom for the storage of personal effects or money. It is strongly recommended that the manager that explores the availability of training specifically related to mental health needs. New House, The DS0000017084.V304604.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 New House, The DS0000017084.V304604.R02.S.doc Version 5.2 Page 26 - 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!