Inspection on 06/06/06 for Pax Care Home

This inspection was carried out on 6th June 2006.

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 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

Pax Care Home 18/05/07

Pax Care Home 25/11/05

Pax Care Home 08/06/05

Pax Care Home 01/03/05

Pax Care Home 03/06/04

Pax Care Home 20/01/04

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

CARE HOME ADULTS 18-65 Pax Care Home 132-134 Pytchley Road Rugby Warwickshire CV22 5NG Lead Inspector Patricia Flanaghan Key Unannounced Inspection 6th June 2006 12:30 Pax Care Home DS0000004354.V298508.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 Pax Care Home DS0000004354.V298508.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. Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pax Care Home Address 132-134 Pytchley Road Rugby Warwickshire CV22 5NG 01788 575009 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 A H Ribeiro Alvin Anthony Ribeiro Care Home 2 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2) of places Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Registration The registration relates to being the registered manager for Pax Care Home accommodating two service users only. Hours worked per week That the registered manager, Alvin Ribeiro, works no more than twenty one hours per week as a medical practitioner and one day per week at Minster Care Home in Coventry. Training That Alvin Ribeiro undertakes training in the following subjects within 12 months from the date of registration: Mental health awareness Management and supervision Person-centred care Evidence of the training must be provided to the Commission for Social Care Inspection. 4. Service User Category Registration is for a maximum of two service users in the category mental disorder, excluding learning disability or dementia. Service users may be of either gender. 25th November 2005 3. Date of last inspection Brief Description of the Service: Pax Care Home provides accommodation for 2 service users who have enduring mental health needs. A third moved out last year. The current registration has been amended to reflect that there are only two appropriate bedrooms at this house. The accommodation is half of the ground floor of a detached house offering single bedrooms, a dining room and small lounge area, as well as access to a large lawned garden. This is part of providers family home where they live with their two grown up children. A majority of the care is provided by family members and by two care staff who are employed Monday to Friday 8 am to 5 pm. The property is within walking distance of Rugby town centre, as well as situated on a bus route. The manager has advised that the current weekly fees for a place in the home is £336.00. Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. The manager of the home also completed and returned a questionnaire containing further information about the home, as part of the inspection process. This unannounced inspection visit took place on Tuesday 6th June between 12.30pm and 10.00pm. The two current residents were spoken with, as well as staff, the registered provider and the registered manager A number of records, such as care plans, staff files and fire safety records were also sampled for information to inform this inspection. Both residents returned questionnaires indicating that they were happy with the service provision at the home. What the service does well: The home is in a comfortable setting with a large garden giving the residents a pleasing outlook. The atmosphere in the home was very relaxed during the inspection with residents appearing happy and comfortable with the staff on duty. Care plans and some risk assessments are in place for the people living at the home, including details of their routines and their likes and dislikes so that staff have the essential information necessary to meet people’s care needs in the way they like. People’s health needs are addressed using support from the GP and good range of appropriate health professionals. Both the owners and the two members of staff showed genuine commitment to good care and support and had a good understanding of the needs of the people they were helping. There have been no complaints at the home since the last inspection. Both residents said that they are happy at the home and that they like the staff. Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 6 Staff are provided with access to suitable procedures and training to enable them to recognise adult abuse and to report any concerns they may have about residents’ welfare. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pax Care Home DS0000004354.V298508.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 Pax Care Home DS0000004354.V298508.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): 2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. At present, any future residents are not assured that their care needs can be met prior to their admission to the care home. Systems are in place for issuing residents with terms and conditions so that their rights are appropriately safeguarded. EVIDENCE: No new residents have moved into the home during the last year, so it was not possible to fully assess Standard 2 on this occasion. The manager confirmed that any new people referred to the home would be provided with a full assessment and have opportunities to visit and meet with any resident living the in the home before they move in. An appropriate pre-admission assessment was not available and this must be developed by the manager to cover all aspects of standard 2 in the National Minimum Standards, before any new residents are admitted to the home. This will ensure that the service have the necessary information to enable them decide if they can meet a prospective residents needs prior to their coming to live in the home. Resident’s contracts are in place containing details of the service that people can expect from the home and the cost of any additional staff support charges. Information provided by the manager confirms that the fees do not include the cost of personal items, such as hairdresser, toiletries and outings. Pax Care Home DS0000004354.V298508.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, resident’s care and health needs are met. Risk management must be more robust to ensure that strategies to minimise risk are agreed with residents and recorded on the care plan EVIDENCE: Examination of care plans and discussion with the two residents demonstrated that the service is making a commitment towards involving service users in the planning of care that affects their lifestyle and quality of care. Care plans consider all areas of the residents’ life, including health, personal and social care needs. There is sufficient evidence to demonstrate the service is working closely with social workers, community psychiatric nurses and psychiatric services in putting together care plans to meet specific care needs. There is an effective system in place to ensure the care plan is reviewed and updated monthly. There are six monthly reviews taking place at which care managers, interpreters and family members are invited to attend if the resident wishes. Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 10 Residents’ care plans contain satisfactory information about their daily routines and their likes and dislikes which enables them exercise some control over the way in which their care is provided by staff. One of the residents living at the home confirmed that they take part in shopping for groceries and for personal items, such as clothing, with support from staff. This enables this resident to choose the things they like. Risk assessments are not well documented and cross referenced to the care planning documentation. For example, one of the resident’s smokes, but there is no risk assessment in place on managing risks to the other resident or staff, so that staff are clear about when and where smoking is permitted. Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in this home are supported to have access to a satisfactory level of social activities and provided with meals they like. EVIDENCE: One of the residents living in the home attends a number of day centres five days a week. The resident said that he enjoys these visits but sometimes would like more activities to be available at weekends. The manager said that the resident frequently went shopping or to the park at the weekend, but he would discuss weekend activities with the resident and arrange a programme to suit his wishes, if possible. The other resident prefers to remain in the home watching Asian programmes on satellite television and chatting to staff. A review of this resident’s file evidenced that at a recent review she has told her social worker and other healthcare professionals present that she does not wish to leave the home and participate in social and community activities. Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 12 She has also specifically said that she does not want a ‘befriender’ to visit her in the home. When the resident was admitted to the home over 10 years ago she spent a lot of time knitting or crocheting and there was evidence of her work throughout the home. A discussion was held with the registered provider on how the resident could be encouraged to commence this craft again and the registered provider said she would also ascertain if any Asian magazines targeted at females were available to purchase, which the resident may find stimulating. The manager advised that he has recently appointed a member of care staff from the same ethnic background as the residents. This staff member has visited the home and has met with the residents who ‘approved’ her appointment. She is currently undertaking an induction programme provided by the local authority and will initially work under supervision in the home. The home encourages residents to maintain contact with friends and relatives. Resident’s relatives are also invited to support them at their review meetings when they are able to do so and if the resident is agreeable. One of the residents had a recent visit from relatives who lived abroad and had left photographs of themselves, which were displayed, in the bedroom creating a homely feel in the room. A menu is in place based on residents’ preferences, which are recorded in their care planning documentation. All the meals provided are suitable for vegetarians and the main meal is prepared which is appropriate to resident’s cultural needs. Comments made by residents indicate that they enjoy the food provided and they were seen to enjoy their evening meal. Suitable records are in place for monitoring the dietary intake of both residents. A fruit bowl was available in the dining room for the residents to help themselves to fresh fruit. Pax Care Home DS0000004354.V298508.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with appropriate support to meet their personal care and health needs. Medication policies and procedures ensure that medication is managed safely. EVIDENCE: Comments by the two residents and responses recorded in questionnaires (sent to the residents as part of the inspection process), indicate that they enjoy living at the home and are happy with the care provided. Discussion with the residents and staff plus entries in resident’s health records indicate that the home supports people to access appropriate healthcare support where required. One person’s records demonstrate that he has been supported to access an extensive range of consultants and health professionals and provided with specialist equipment to meet his changing mental and physical health needs. An examination of the health records indicates that residents are supported to access routine checks, such as GP appointments, dentist and optician check ups. Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 14 A lockable cupboard is in place for the safe storage of medication. The medication in the cabinet was found to be correctly labelled so that it is clear whom the medication belongs to. Medication sheets are being used to appropriately record resident’s medication and systems are in place for booking medication into and out of the home so that it is properly accounted for. Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are adequate policies and procedures in place for responding to any complaints that residents might have and to protect them from abuse, but the Registered Manager needs to do more to make the complaints procedure more relevant to residents fist language and understanding. EVIDENCE: There have been no complaints to the Commission for Social Care Inspection since the last inspection and the manager confirmed that there have been no complaints made directly to the home during the same period. Both residents said that they had no concerns or complaints and that they are happy with the service provided at the home. At the last inspection visit the manager was reminded of the requirement to ensure that the complaints procedure is available to residents in a format that they will understand. However, the procedure is still presented only in English, although this is both residents’ second language and it does not take account of the level of residents’ literacy in this language. It is accepted that whilst the complaints procedure is adequate, the Registered Provider needs to demonstrate that residents actually understand it and ensure that they have ready access to independent advocacy or supporters who will raise concerns on their behalf. Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 16 Discussions with both members of staff and training information provided by the manager demonstrates that staff are provided with adult abuse training. Staff comments confirmed that they are provided with access to the abuse and whistleblowing policies so that they know how to raise any concerns they might hold. Pax Care Home DS0000004354.V298508.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good providing service users with an attractive and homely place to live. EVIDENCE: The home is intended to provide a small domestic home-like environment reflecting the small number of residents accommodated and their particular needs. Situated in a residential area, reasonably close to the town centre and its amenities, the home is in a quiet location with little traffic. The premises are detached and serve both as the Registered Persons’ family home and a care home. Resident’s accommodation is distinct and completely selfcontained providing them with adequate bedroom and communal space. The home continues to provide service users with a reasonably comfortable and safe environment in which to live. It is constructed in a style compatible with those that surround it thus making it largely indistinguishable and it is being maintained in good structural and decorative order. Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 18 Resident’s bedrooms are spacious, but as pointed out at the last inspection, they are poorly furnished with the quality of furnishings being variable. For example, a chest of drawers, wardrobes and bedside cabinets are old, worn and unattractive. The manager provided evidence of a quotation received for new carpets and new furniture for resident’s bedrooms. He advised that the resident’s will chose their own furniture and carpets from samples provided by the company. It was noted at the last inspection that there are no restrictors on the window openings in resident’s bedrooms. Even though these rooms are on the ground floor, fitting restrictors, which enables sufficient ventilation but would deter service users attempts to climb out or intruders to enter, is likely to improve safety and security. The manager said that this remains outstanding and restrictors will be fitted during the refurbishment of the home. The manager expects the refurbishment programme to be completed by the end of the year, with priority being given to resident’s bedrooms. The laundry facility was clean and in good order and there is documented evidence to show that monthly maintenance checks on the environment are taking place. The COSHH cupboard was locked at the time of the visit and liquid soap and paper towels were available in the laundry area. On the day of the inspection the home was clean and tidy with no offensive odours apparent. Pax Care Home DS0000004354.V298508.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 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents in this home receive care and support from staff who are competent to undertake the role, and are protected by sound recruitment procedures. EVIDENCE: Prospective staff complete an application form and two written references are obtained as part of the recruitment process. An enhanced criminal records bureau check is obtained for all staff before they commence work in the home. The file of a recently appointed member of staff was examined in detail. This confirmed that suitable vetting checks and references are taken up by the organisation as part of the recruitment process, to ensure that staff are suitable to work at the home. Staff undertake a formal induction and each staff member has a training and development record. Training is regular and ongoing; discussion with the provider and staff indicated that recent training had included food hygiene and Fire Safety. One member of staff is currently undertaking a National Vocational Qualification (NVQ) Level 3 in Care. In light of the residents’ ethnicity and disabilities, equal opportunities, including disability awareness are identified as priority training for staff. Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 20 The manager has recently purchased a training pack from Age Concern entitled ‘Cross Cultural Care Pack for Carers’. He intends to provide training for all staff in this subject as soon as possible. A requirement of the last inspection was for staff to be provided with supervision, to ensure consistency in care practice. Evidence was available to confirm that this has been commenced, but remains an ongoing requirement. Pax Care Home DS0000004354.V298508.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, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the home is appropriately managed and monitored, but a systematic quality monitoring system should be developed to ensure standards in all areas are continually monitored and improved. EVIDENCE: The registered manager is a qualified and practising medical doctor who has had some supervisory experience in residential care in his capacity of registered provider of a care home for older people. Evidence was seen that the manager is in the process of completing the final module in the Certificate in Management Studies (CMS). This qualification will be accepted as meeting the management component of Standard 37. Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 22 There is currently no formal system of quality assurance within the home although staff opinion on the running of the service is invited during regular staff meetings and daily handovers. Ways should be examined of implementing a formal quality assurance system, which includes regular consultation with residents, their representatives and other interested parties. The pre-inspection questionnaire completed by the manager shows that all the essential health and safety checks are being routinely carried out at the home. Fire records were examined and there was evidence that fire equipment is being appropriately tested and checked to ensure it is maintained in good order and suitable arrangements are in place for the testing of electrical equipment so that it is safe to use. There are no records of fire drills and the Registered Person must therefore ensure that these are carried out at the intervals recommended by the Fire Service and that the outcome and any corrective measures taken are recorded. The manager has recently undertaken a 2 day Fire Safety training course and stated he would conduct a fire drill in the home within the week. Pax Care Home DS0000004354.V298508.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 X 2 2 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 24 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 YA2 Regulation 14 Requirement The Registered Person must ensure new service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. The Registered Person must ensure new devise a clear risk assessment strategy for staff to effectively manage and reduce any potential risks to residents and staff. The Registered Person must ensure that the complaints procedure is presented in a form that most effectively communicates its contents to service users. (Previous timescale of 28/02/06 not met). Timescale for action 30/09/06 2 YA9 13(2)(c) 30/09/06 3 YA22 22 (2) 30/09/06 Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 25 4 YA24 23(2)(d) The Registered Person must address the following: i. Fit restrictors to service users’ bedroom windows so that there is sufficient ventilation, but reduced risk of their occupants being at risk by trying to climb out or intruders attempting to enter. ii. Replace the worn and dated furniture in service users bedrooms, encourage them to personalise their room and act to make the bedrooms and bathroom less stark. (Previous timescales of 01/09/04, 01/06/05, 07/10/05 and 28/02/06 not met). 30/09/06 5 YA35 18 The Registered Person must ensure training is provided for staff on equal opportunities including disability awareness. (Previous timescales of 01/10/04, 01/06/, 07/10/05 and 28/02/06 not met). The Registered Person must make arrangements for staff supervision to be undertaken at the frequency specified in standard 36 and an annual appraisal all of which must be recorded. (Previous timescales of 01/10/04, 15/04/05 and 07/10/05 and 28/02/06 not met). 30/09/06 6 YA36 18 30/09/06 Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 26 7 YA39 24 The Registered Person must 30/09/06 ensure effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. The Registered Person must ensure fire drills are carried out at the frequency recommended by the Fire Service and are recorded. 30/09/06 7 YA42 23 (4) Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Pax Care Home DS0000004354.V298508.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!