Inspection on 17/11/05 for Orchard End

This inspection was carried out on 17th November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Orchard End 24/03/09

Orchard End 03/04/07

Orchard End 16/03/06

Orchard End 21/02/05

Orchard End 26/07/04

Orchard End 18/03/04

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 Orchard End Church Lane Minsterworth Glos GL2 8JJ Lead Inspector Ms Barbara Davies Unannounced Inspection 17th November 2005 10:00 Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 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 Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 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. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Orchard End Address Church Lane Minsterworth Glos GL2 8JJ 01452 750587 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) Orchard End Limited Caroline Hopkinson Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2005 Brief Description of the Service: Orchard End is a residential care home for 12 adults who have a learning disability and may demonstrate challenging behaviour. Accommodation is provided in two separate units, one of which is the main house and the other a bungalow. The house has a large lounge/dining room, another lounge, main kitchen, small kitchen, computer room, toilet and a ground floor bedroom with its own shower. On the first floor there is a bathroom and three bedrooms, two of which have their own en-suite toilets. In another wing of the house on the first floor there are two bedrooms, a bathroom and two small offices. The bungalow has a lounge, conservatory which is used as a dining room, small kitchen, bathroom and six bedrooms, two of which have en-suite toilets and two have full en-suite facilities. The home is surrounded by large level gardens which are maintained to a high standard. There is also a swimming pool, and a sensory garden built in a Japanese style. The home keeps a few chickens and has an aviary. The home is situated in a rural environment on the banks of the River Severn approximately 8 miles from the City of Gloucester. The home is one of four homes known as Orchard End Ltd owned by C.H.O.I.C.E. Ltd. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the home was unannounced and commenced at 15:15hrs on 17th November 2005. It took place over four and a half hours during the afternoon and early evening. The unit manager was spoken to during the inspection and the Inspector joined staff and service users in the conservatory of the bungalow for a short period of time. The manager accompanied the inspector on a tour of the communal areas of the building. Bedrooms of some of the service users were also seen. Files relating to two service users were inspected and other records kept in the home were examined. The statement of purpose and service user guide were also seen. Eight of the service users were on holiday when this inspection took place and two of the service users were out of the unit on other activities. What the service does well: What has improved since the last inspection? There were no requirements made at the previous inspection and the home has responded to most of the recommendations that were made. The home continues to offer a high quality service. Service users’ contracts/ terms and conditions are now dated and are signed by either the service user or their representative as well as the home’s manager. The home is introducing a new pictorial format for placement plans which will make them more accessible to service users. Service users are now involved in discussions about the information that they would like to be included in these. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 6 A procedure has been introduced for ensuring that service users are offered snacks on a regular basis. The evacuation procedure has been amended to include the details of the assembly point. These are now displayed around the building. 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. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 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 Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 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, The needs of service users are effectively assessed prior to admission and a programme of care planned accordingly. Service users are consulted and involved in planning their own care. They are able to make choices about what they do and are given the opportunity to voice any changes that they would like to see in the way the home operates. EVIDENCE: The home has published a statement of purpose and this describes the facilities and services provided by the home. There was evidence that this has recently been reviewed and updated to take into account any changes that have occurred. A version of the statement of purpose has been published in a pictorial and word format that some of the service users, with assistance, will be able to understand. Information obtained by the home in advance of admitting a new resident was examined. There was evidence that prior to agreeing admission it is practice for the project development manager to complete a comprehensive needs assessment to determine whether the placement is appropriate. A transitions meeting- involving senior managers of the home, members of the Community Learning Disability Team and the parents of the individual concerned will then take place prior to admission to design a package of care to meet the needs of the service user to be admitted. Minutes of one such meeting showed that a number of tasks had been identified as requiring completion before a service user could be admitted and individuals had been identified as having Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 9 responsibility for ensuring these were completed. There were plans on file that showed how the home is going to meet the specific care needs of service users including a behaviour management plan. Copies of the written contract that has been established between the home and the service user were evident on the two files examined during the inspection. The contents of the contract did not cover all of the matters specified within the standard, such as room to be occupied. However, as recommended during the last inspection, contracts are now dated and are signed by the home’s manager and also by the service user to whom it relates or by their representative. It was noted that the style and language of the contract was complex and consequently service users would not be able to access it independently. This was discussed with the unit manager who indicated that it was a matter that the home had identified as requiring attention. However the manager did say that it is practice for the contents of the contract to be explained to service users or their representatives before they are asked to sign it. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 10 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, 8, 9 and 10 Service users are consulted and involved in planning their own care. They are able to make choices about what they do and are given the opportunity to voice any changes that they would like to see in the way the home operates. EVIDENCE: Service user plans have been developed for all the people living in the home and these show how the home is working, on a day-to-day basis, with each person living there. The unit manager said that senior staff review and update two service user plans each month. There was evidence in one of the files examined that plans had been reviewed and updated twice a year as described. Plans describe the actions to be taken by staff to support service users to develop skills and to achieve what they want to. The unit manager said that the home is in the process of introducing pictorial plans for all service users, by using a computerised widget and word programme. It was reported that so far these plans have been completed for four people with the remainder to be completed over the next four months. The home is commended for introducing this initiative. The manager said that when compiling the plans she meets with individual service users to determine what they would like to be included. One service user for whom a plan has already Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 11 been completed has been quite specific about how she would like staff to attend to her personal care needs. Where appropriate, plans also include contributions from parents/carers and the Community Learning Disability Team. Some staff have been trained in the use of ‘Makaton’ as a means of communicating with service users and other staff are scheduled to attend this training. Most members of the staff team have attended training in ‘total communication’ and throughout the inspection staff were observed to use a variety of techniques to communicate with residents. Written records kept by the home show that the staff involve service users in discussions about how they want to be looked after and also about any changes they would like to see in the way that the home operates. The manager and staff said that the residents meet formally with the staff once a month. The unit manager said that there is an acknowledgement that some of the residents are not comfortable within a group setting and that these people will be spoken to individually. Records are kept of meetings that take place. They show the matters raised by individual service users and make a note of the people who chose not to take part in the meeting. Informal consultation is said to take place on a daily basis with service users being asked about the activities they would like to do and the food they would like to eat at mealtimes. This was evident throughout the inspection. The manager said that service users are involved in selecting the décor of their bedrooms. The décor in the bedroom of a male resident was seen to reflect his interest in a particular football team and another bedroom was in the process of being redecorated while it’s occupant was on a unit holiday. Service user plans seen during the inspection take into account the stated preferences of the people concerned. Service users are supported to participate in a wide range of individual and group activities. The manger said that staff are well-versed in the precautions that need to be taken to ensure the safety of service users whilst undertaking these activities however, the manager indicated an awareness of the need for individual risk assessments to be completed for service users in relation to the activities in which they participate. Information and records relating to the operation of the home are kept securely in the manager’s office on the first floor of the main building. Personal information about service users is kept in locked cabinets in the conservatory of the bungalow. The manager recognises that this arrangement is not ideal as service users have access to this area. The registered manager spoke of planning permission having been sought and obtained to create office space within the bungalow. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 12 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, 14, 15 and17 Services are provided to service users that assist them to develop to their potential, to participate in community-based activities and to lead fulfilling lives. The home supports service users to maintain links with their families and friends. Healthy and nutritious meals are provided. EVIDENCE: Service user plans show that a range of therapies are available to service users. Activity plans show that that the home is responsive to the spiritual needs of individual residents. The unit manager said that at the request of one family, arrangements had been made for a Greek Orthodox priest to visit the home three times a year to bless their son’s bedroom. A pictorial activity plan is in place for each service user living in the home. The plan shows that, although none of the people living in the home are currently employed, people are supported to make constructive use of their time and to acquire new skills. Plans for some service users included attending college courses that have been established for people with disabilities. One person for example attends a cookery course at college. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 13 Activity plans showed that service users also attend community groups that have been established specifically for adults with learning disabilities. Staff said these groups provide an opportunity for some of the residents to socialise without staff being present. Activities in which service users participate include: trampolining at a local leisure centre, horse riding, walks along the riverbank and attendance at the Rainbow club. Opportunities are also created for service users to engage in activities in the home. Television, video and keyboard facilities are provided and a range of board games is available. Some of the residents have their own television and video in their bedrooms. During the summer service users have access to a swimming pool in the grounds. The organisation has access to a caravan sited at a caravan park by the sea and service users, supported by staff, are able to have use of this throughout the summer. A group of service users supported by staff were taking a five day break at ‘Centre parks’ at the time of the inspection. Service user plans show the arrangements that are in place for individual residents to maintain contact with their families and friends. Records show that service users are supported to maintain contact as described in the plans and that visits to the home by relatives and friends are encouraged. The unit manager described the arrangements for preparing meals for service users. The home has a housekeeper who prepares the lunchtime and evening meals during the week. At weekends meals are prepared and served by the care staff on duty. The manager said that only the members of staff who have received training in the safe handling and preparation of food are involved in the preparation of meals. A record is kept of meals served and these show that varied, wholesome and nutritious meals are served to residents. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 14 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 The home is sensitive and responsive to the needs of service users and involves them in deciding how they would like to be cared for. EVIDENCE: Service user plans describe the arrangements for staff to provide support to service users. These are designed to take into account the stated preferences of individual service users. As mentioned in standard 8, one service user who is unable to communicate verbally has been helped to compile a pictorial plan describing her likes and dislikes. The plan also contains detail of how she would like her personal care needs attended to, in particular that she does not want male staff to be involved. The unit manager said that her request for only female staff to be involved in performing these tasks has been responded to. The manager said that wherever possible members of staff of the same gender as the service users perform personal care tasks. The unit manager said that there is a daily routine in place for each service user but that the routines still allow for flexibility about the time that service users go to bed. During the inspection one person had gone to bed during the early evening for a rest but staff said that in such circumstances it is usual for him to get up later in the evening to spend time with staff and to have a late supper. The home has staff awake during the night and the manger said that this arrangement also allows service users to stay up later if they want to. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 15 Records held in the home for service users contain details of their health needs and the actions to be taken by staff to meet them. There was evidence that service users are registered to receive services from a G.P, dentist and optician. Also evidence that arrangements are made for service users to attend medical examinations at appropriate intervals. Details of any treatment and medication required are also recorded. Records of training for staff show that training in first aid is given to staff during their induction period and that this is repeated every three years. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 16 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 Appropriate measures are in place to safeguard the welfare of residents and to provide them and their representatives with the opportunity to raise concerns. EVIDENCE: The home has a complaints procedure that tells residents about the action they can take if they have any concerns. This has been translated into a pictorial and word format by using a widget computer programme. Copies are available to residents in a communal area in the bungalow and there is also a copy on their file. The unit manager said that information is also given to parents and relatives about how they can make complaints. The manager reported that one complaint has recently been received and an appropriate process for managing this was described. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 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 and 28 The extensive grounds and the interior of the home are maintained to a high standard, providing a range of homely, comfortable facilities for service users. Service users are involved in deciding how their bedrooms are decorated. EVIDENCE: Service users have access to facilities within both the main building and the bungalow. The décor and environment within both premises was mostly maintained to a high standard. The exception to this was an area to the rear of the main building that contains a downstairs toilet. This ceiling in this area was found to be in a poor state of repair. The manager said that this area is likely to be subject to alterations within the near future and an application has been submitted to the local council for building regulation approval. Each service user has a single room the size of which complies with the measurements stated in standards. Rooms have appropriate furniture and fittings and also have wash hand basins. Communal toilets and bathrooms are within close proximity of the bedrooms. It was pleasing to see that each bedroom contained an abundance of personal items belonging to the service user concerned. The manager said that requests from service users to have Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 18 their bedrooms decorated in a particular way will be responded to. The bedroom for one service user had been decorated taking into account his liking for a particular football team. The communal facilities in both the bungalow and the main building are suitably furnished and provide comfortable, domestic style facilities for service users. The number of communal rooms is sufficient to allow a number of activities to take place at the same time and to allow service users to pursue separate activities should they wish. The home is set within generous grounds with an outdoor swimming pool. The grounds are well tended but some of the edging stones near the gate to the river bank are broken and in need of replacing. Appropriate steps have been taken by the home to ensure that the home and the grounds is a safe environment for service users. The home has recently installed new gates at the end of the drive and by the path leading to the bank of the river. A risk assessment has been completed on the house and the grounds and this includes the strategies in place to prevent accidents occurring at the swimming pool. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 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, 33, 35 and 36 EVIDENCE: The company holds ‘The Investors In People Award’ which is a recognition of the it’s work with the people it cares for and the support and training offered to staff. The manager of the home is appropriately qualified holding an NVQ4 in Care and the Registered Care Managers Award. The deputy manger holds an NVQ3 in Care and is also an NVQ assessor. More than 50 of the home’s staff team are qualified in NVQ level 2 with other staff currently engaged in this training. This means that the home’s practice in this area exceeds that specified in standards. The manager said that the organisation has a programme of training in place and that all staff have completed training in core matters such as moving and handling and emergency first aid. Records of training confirm this to be the case. Some of the staff have attended training that provides specific knowledge about adults with learning disabilities and the manager said it is intended to provide training in alternative methods of communication to all of the staff. An up to date list of training completed by all staff is kept on the office wall together with dates that have been identified for refresher training to be provided. Throughout the inspection the manager and the staff were observed to speak to service users respectfully and to make an effort to communicate with them through their preferred method. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 20 The manager reported that there are usually 8 members of staff on shift to work with 12 service users but that there would never be less than six staff. Duty rosters confirmed this to be the case. Staff reported that the staffing levels allow work to take place individually with service users and also allows service users to be supported to pursue their own interests. The level of staff absence due to sickness was reported to be low and the manager reports having contingency measures in place to provide for this eventuality. Staff reported that these would normally involve a member of the staff team working extra hours. The manager said that they aim to have staff meetings once a month with a written record being made of the issues discussed. Records examined showed that although meetings have not always taken place each month, they have still occurred at a frequency that exceeds that specified in standards. Records of individual supervision sessions for staff show that during the preceding twelve months period, the frequency at which staff received individual professional supervision varied. Some but not all staff had received supervision at the frequency specified in standards. A record is kept of all the sessions that have taken place and this showed that the topics discussed do not include all the matters specified within this standard. For instance two of the records did not contain any detail to show that work with individual service users is discussed or monitored within supervision. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 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 and 42 The home is well managed EVIDENCE: The manager of the home is registered with the Commission for Social Care Inspection. She has successfully completed the Registered Manager’s award and NVQ4 in care. There was evidence that the relevant health and safety checks were maintained. The record of checks completed n relation to fire equipment showed that checks are completed at the required frequency. The manager said that the notices of the evacuation procedure have recently been amended to include details of where the assembly area is. Some of the evacuation notices displayed around the home have been translated into pictorial format for the benefit of the clients. This is good practice. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x 3 Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 x 3 3 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x x 3 x x LIFESTYLES Standard No Score 11 3 12 3 13 x 14 3 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Orchard End Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x DS0000055595.V260641.R01.S.doc Version 5.0 Page 23 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 YA9 Regulation 13 Individual risk assessments must be completed for all service users in respect of the activities in which they participate. A timescale must be identified within which separate office space will be created in which files belonging to residents can be kept securely. Remedial work must be completed to the lobby at the rear of the main building (by the downstairs toilet) to ensure it is in a good state of repair. Supervision must take place at least six times a year for all staff. An up to date written record should be kept of each session detailing the matters discussed. Timescale for action 31/03/06 2 YA10 23 30/04/06 3 YA24 23 30/06/06 4 YA36 18(2) 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 24 No. 1. 2 Refer to Standard YA5 YA5 Good Practice Recommendations The home should review the content of the contract and present it in a format/language that is appropriate to each service user’s needs. The home should check that the contents of the contract covers all the matters specified in standard 5.2 Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Orchard End DS0000055595.V260641.R01.S.doc Version 5.0 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. 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