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Inspection on 01/12/05 for Petersfield Care Home

Also see our care home review for Petersfield Care Home for more information

This inspection was carried out on 1st December 2005.

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 27 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is comfortable and furniture is of good quality. Service users enjoy having a bank account and spending their own money on things they like. Service users have opportunities to make choices about some areas of their lives. One service user was clearly very comfortable making lunch in her kitchen and knew where everything was kept. Staff have good knowledge of service users needs.

What has improved since the last inspection?

Soap and towels have been provided in bathrooms. A shower curtain has been fitted in one bathroom. Door locks that were broken have been replaced. The fire alarm is tested each week to make sure that it is working properly.

What the care home could do better:

Care plans and risk assessments that explain how to meet individual needs and keep people safe need a lot of work to protect the service users living at the home. There are no daily records that explain how service users have made decisions and choices. Some service users have not been offered a chance to do some things for themselves, such as cooking. There need to be more staff in the home to help people go out and do things they want to do. Staff training needs to improve to help them support the people that live in the home more effectively. Some health and safety practice needs to improve to protect people that live in the home.

CARE HOME ADULTS 18-65 Petersfield Care Home 60 St Peters Road Handsworth Birmingham West Midlands B20 3RP Lead Inspector Julie Preston Announced Inspection 1st December 2005 10:00 Petersfield Care Home DS0000017053.V263375.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 Petersfield Care Home DS0000017053.V263375.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. Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Petersfield Care Home Address 60 St Peters Road Handsworth Birmingham West Midlands B20 3RP 0121 515 1654 0121 515 1654 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) Ms Vinette Campbell Ms Vinette Campbell Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 5 adults, under 65, with learning difficulties (5 LD) Showers must be replaced with either Mira Advance or Triton Millennium showers, which do not reach a higher temperature than 43oC, on or before 31 Mar ch 2004 Window restrictors must be fitted to all first floor windows on or before 28 February 2004. All bedroom doors must be fitted with a master key system on or before 31 March 2004 A full fire alarm system conforming to BS5839; Part 1, 2002, to L1 standard is fitted on or before 31 March 2004. That other matters arising from the Fire Officer`s report dated 22 December 2003 are met as stated in the action plan submitted to the NCSC on or bef ore 29 February 2004 The star lock on the door of the first floor bedroom must be removed and the door must comply with fire safety standards prior to a service user movin g into the room. A satisfactory report is received from Environmental Health and any outstanding matters will be met within the agreed timescales. 10/05/05 3. 4. 5. 6. 7. 8. Date of last inspection Brief Description of the Service: Petersfield Care Home is situated in the Handsworth area of Birmingham, close to the Perry Barr shopping centre. The home is located close to places of worship, public transport links and local amenities. Bedrooms are on the ground and first floor of the property and the ground floor bedroom has an en suite facility. There is one shared bedroom. Communal space consists of a through lounge/dining room and separate kitchen. Furniture, fixtures and fittings are of a good standard. The registered provider lives on the premises and the home is staffed by members of her family. Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over half a day and included input from an expert by experience (Exbyex) from Sandwell People First. The Exbyex spent time with a service user who was present for the inspection and spoke to her about her experience of living in the home. Records about the way service users needs are identified and met were looked at as well as staff training and health and safety records. A brief tour of the premises took place and the Exbyex was invited to look at a service user’s bedroom. There had been no complaints received at the home or at the Commission for Social Care Inspection (CSCI). This report should be read in conjunction with the report made following the visit of 10th May 2005. What the service does well: What has improved since the last inspection? What they could do better: Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 Page 6 Care plans and risk assessments that explain how to meet individual needs and keep people safe need a lot of work to protect the service users living at the home. There are no daily records that explain how service users have made decisions and choices. Some service users have not been offered a chance to do some things for themselves, such as cooking. There need to be more staff in the home to help people go out and do things they want to do. Staff training needs to improve to help them support the people that live in the home more effectively. Some health and safety practice needs to improve to protect people that live in the home. 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. Petersfield Care Home DS0000017053.V263375.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 Petersfield Care Home DS0000017053.V263375.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): None of these standards were assessed. EVIDENCE: Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The processes of care planning and risk assessment are poor and do not protect service users or ensure that their needs are assessed and met. There are some opportunities for service users to make decisions about their lifestyles. EVIDENCE: Two care plans were sampled during the visit and the Exbyex spoke to a service user about her care plan. The plans seen were not completed in sufficient detail to enable the reader to understand how to meet the person’s needs. For example, one plan referred to a service user being “very vulnerable” but did not explain what this meant or how to protect the person. Within the same plan, information was seen that described the signs to be aware of that might indicate a decline in the service user’s mental health. There was no written record of how to respond and take action to protect the person. The home does not keep daily records, which meant there was no evidence of care plans being followed. This does not enable staff to monitor service users needs or review care plans in the event that needs change. Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 Page 10 Service users care plans are not accessible to them, although a member of staff advised that individuals are involved in compiling their plans. The Exbyex felt strongly that service users care plans should include pictures and photographs as a means of making them more accessible and including the person in the development of their own plan. Risk assessments were sampled and found to be in need of considerable development to ensure that controls are identified to enable service users to take responsible risks based on their strengths and needs. It was of concern to note that no risk assessment had been completed for two service users that go out without staff support. The inspector by no means wishes to prevent service users from this independence however, it was not evident that any assessment of the risks to each person had been taken place or minimised through appropriate control measures. Immediate requirements were made that this assessment be completed for each service user within three days of this inspection. Other risk assessments were seen to be undated so it was not possible to establish that they were reflective of service users current needs. In one file the personal care guidelines referred to a manual handling assessment dated 2004. This was missing from the record. In another file there was no record of any risk assessments being completed. The Exbyex was informed by a service user that she has a bank account and has help to withdraw her money to spend on things she likes, such as clothes and toiletries. The absence of daily records made it difficult to establish how individual choices have been made, however the Exbyex commented that a service user had been offered opportunities to attend a day centre, which she had turned down as unsuitable. The Exbyex went on to say that she found it reassuring that the service user had the confidence to tell staff about her preferences. This example reinforces the need for the home to develop individual care plans for service users that reflect their needs and aspirations. Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 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, 17 The systems in place to record service users involvement in activities are not sufficient to determine that they are provided in accordance with individual needs and preferences. Service users have some opportunities to take part in food preparation and shopping. Further development will enable service users to have greater opportunities to maintain their independent living skills. EVIDENCE: One service user was at home during this inspection. The Exbyex spoke to this person about the things she did during the day and was told that she went out shopping, to the cinema and pub and had enjoyed going to the ballet. As there were no other service users present and no daily records maintained within the home it was not possible to evidence that appropriate activities are offered in accordance with service users needs and preferences. During the inspection, a meal of sandwiches was prepared by the service user. The Exbyex commented that the person seemed comfortable in her kitchen and knew where everything was kept. The service user said that she didn’t Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 Page 12 cook hot food at home, but had done so in the past. The individual care plan for this service user identified that she was interested in cookery and this should be followed up to provide opportunities for the future. Staff confirmed that service users are included in shopping for food and the service user said she enjoyed meals in the home. The deputy manager said that no shopping list is drawn up as service users likes and dislikes are well known. The Exbyex felt that service users could be included in devising a list to assist them in developing daily living skills. The kitchen in the home is spacious and provides ample seating for service users. Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 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 Some development of personal care plans is needed to ensure that service users preferences and routines are assessed and met. The arrangements in place to assess, monitor and record individual health care needs are poor and do not enable service users to maintain good health. EVIDENCE: Some information relating to service users personal care needs was maintained within the records seen. However further development is needed to ensure that preferred personal care routines are clearly recorded and that any moving and handling needs are assessed and an appropriate plan implemented to enable those needs to be met. The inspector and Exbyex were however pleased to note that service users are assisted to shop for their own clothing and toiletries and that times for getting up and going to bed were flexible within the home. A psychology report dated June 2005 was observed and referred to the need to monitor changes in a service users mood and behaviour. There was no evidence that this had been done. Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 Page 14 A record of health care appointments for one service user was noted to be blank and it appeared that the person had not seen a GP or dentist since moving to the home in February 2004. A risk assessment for a service user that self-administers some medication stated “no concept of risks so full records to be maintained.” There was no information to describe what this meant. This assessment also referred to the records being audited by the Regional Manager, of which there is none at the home. The inspector believed that this record did not accurately reflect the service provided within the home and was misleading in content. Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has a written complaints procedure. This needs to be made available to service users representatives to provide further protection to service users. Some minor amendment to the adult protection policy is needed for the protection of service users. EVIDENCE: The home has a complaints procedure and a service user stated that she would speak to the registered manager if she needed help to resolve any problems. Staff at the home are members of the same family and the Exbyex raised concern about the difficulties that may be encountered by service users who wish to complain about staff that are related to each other. This was discussed with the deputy manager who said that there were plans to appoint more staff outside of the family, which she believed would address this concern. It is important that service users and their relatives are made aware of the role of the CSCI in complaints investigation to provide further protection in this area. The home has an adult protection policy. This is in need of updating to include contact telephone numbers for the Social Services Department and CSCI. Two members of staff at the home have received training in adult protection. Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 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): 26 There have been some improvements to offering private space within the shared bedroom at the home. Further work is needed to ensure that service users are happy with these arrangements. EVIDENCE: The Exbyex was invited to observe a service user’s bedroom and made favourable comments about the decoration and furnishings. The inspector observed a shared bedroom on the first floor of the home. The deputy manager said that the two service users had shared the room for over a year and enjoyed being together. Screening has been provided in this bedroom, however it was reported that this is used infrequently. It is necessary that service users continue to be consulted about sharing a bedroom and that arrangements for them to receive visitors in private are considered as part of that process as this has not been done. Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 Page 17 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, 35 Staff at the home are committed to caring for service users however a lack of training and low staffing levels have an impact on the service received by people that live there. EVIDENCE: The staff team comprises of the registered manager and her two daughters. There are no other staff employed to work with the five service users that live in the home. The deputy manager advised that an advertisement had been placed locally to recruit further staff. This is particularly crucial as the deputy manager is due to take a planned leave of absence in 2006. The requirement from the previous inspection is repeated; specifically to evaluate whether there is adequate staff to respond to the needs of the service users. Those staff currently working in the home demonstrate detailed knowledge of service users needs and a commitment to working effectively with them. Observations made by the inspector and the Exbyex indicated that service users feel comfortable with the staff team. The deputy manager was unable to locate the staffing rota on the date of inspection. It is required that a copy of the rota for the period 1-8 December is sent to the CSCI. Examination of staff training records showed that some training is outstanding. There was no evidence that staff had completed training in Basic Food Hygiene, First Aid, Fire Safety and Manual Handling. Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 Page 18 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, 42 The management arrangements need resolving to ensure that the service users benefit from a well run home. Some areas of health and safety practice are poor and do not protect the service users living in the home. EVIDENCE: The management of the home remains the same as at the last inspection. The registered manager has relinquished the majority of her role to her daughter who is the deputy manager. The deputy manager stated that she plans to apply to the CSCI for registration as the home’s manager. This is now required. The records for the service of fire safety equipment were noted to be up to date and there was evidence that the fire alarm system is tested on a weekly basis. Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 Page 19 Hot water temperatures were seen to have been sampled and tested on a regular basis. A number of concerns with regards to health and safety were raised with the deputy manager. Rugs on tiled and laminate floors presented a trip hazard and some fire doors were wedged open. The last entry for the testing of emergency lighting was noted to be September 2005. Immediate requirements were made that these matters be addressed within 24 hours of the inspection. There was no fire risk assessment for the safe placement of service users during an emergency and there was no evidence that service users had taken part in a fire drill. There were no data sheets available to describe the usage of Control of Substances Hazardous to Health (COSHH) products, which was a requirement of the previous inspection. This report has identified that risk assessments relating to individual service users are in need of development. Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 Page 20 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 X X X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 2 X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X 2 X X X X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X X 1 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Petersfield Care Home Score 2 1 X X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 1 X DS0000017053.V263375.R01.S.doc Version 5.0 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(1-2) Requirement Each service user must have a written plan of care that describes how their needs in respect of health and welfare are to be met and must be reviewed on a regular basis to reflect changes in needs. Service users must have access to their individual plan. The care plans for the service users described as being “ very vulnerable” and at risk of experiencing a decline in mental health must be reviewed and updated to clearly record how their needs are to be met. Daily records must be maintained for each service user to demonstrate that care plans have been adhered to and for the purposes of monitoring individual needs. Risk assessments must be dated and signed. Risk assessments must be reviewed at least six monthlysooner if needs dictate. A risk assessment must be completed for each service DS0000017053.V263375.R01.S.doc Timescale for action 01/02/06 2 YA6 15(1-2) 01/02/06 3 YA7YA6 12(1)(a) 01/02/06 4 YA9 13(4)(a-c) 01/02/06 5 YA9 13(4)(a-c) 04/12/05 Petersfield Care Home Version 5.0 Page 22 6 YA9 13(5) 7 YA13YA12 16(2)(m,n) 8 YA17 16(2)(h) 9 YA18 12(1)(a) 10 YA19 17(1)(a) Sch 3(m) 11 YA19 12(1)(a) 12 YA19 13(4)(b, c) 13 YA22 22(1-8) user that goes out without the support of staff. Each assessment must identify the control measures in place to minimise assessed risks. Immediate requirement The home must ensure that manual handling risk assessments are in place for all service users. Service users must be consulted about the activities they take part in and opportunities must be provided for these to take place. Service users must be offered opportunities to prepare their own food subject to individual preferences and risk assessment. Clear guidance on how service users prefer their personal care needs to be met, must be included in the service users plan. The home must ensure that recording systems are in place to monitor the mood and behaviour of one service user as stated in the psychology report of June 2005. Health care appointments must be recorded and include the outcome of each appointment to enable accurate monitoring of service users health. The risk assessment for the service user that selfadministers medication must be reviewed to clearly describe the steps that are taken to reduce known risks. The complaints procedure, including details of the role of the CSCI must be made available to service users and DS0000017053.V263375.R01.S.doc 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 Petersfield Care Home Version 5.0 Page 23 their representatives. 14 YA23 The adult protection policy must include the contact details for the CSCI and Social Services Department. 12(3) Service users must be 23(2)(i) included in ongoing discussion about their satisfaction with regard to sharing a bedroom and their opportunities to receive visitors in private. 18(1)(a) The registered provider must advise the CSCI of the arrangements to provide staff in such numbers to meet the needs of service users living in the home. 18(1)a The registered provider must 17(2)Sch4,7 submit a copy of the staffing rota for the period 1-8 December 2005 to the CSCI. 18(1)(a)(c)(i) The registered provider must advise the CSCI of the arrangements to provide staff training in the following areas- Basic Food Hygiene - First Aid - Manual Handling - Fire Safety 8(1-2) The person managing the home must submit an application for registration to the CSCI. 13(4)(a-c) Loose rugs on tiled and laminate floors must be secured or removed. Immediate requirement 23(4)(c)(i) The practice of wedging open fire doors must cease. Immediate requirement 23(4)(c)(v) Emergency lighting must be tested on a monthly basis. Immediate requirement 23(4)(c)(iii) The fire risk assessment must be developed to include information about the safe placement of service users in DS0000017053.V263375.R01.S.doc 13(6) 01/02/06 15 YA26 01/02/06 16 YA32 01/02/06 17 YA32 01/02/06 18 YA35 01/02/06 19 YA37 20/02/06 20 YA42 02/12/05 21 22 23 YA42 YA42 YA42 02/12/05 02/12/05 01/02/06 Petersfield Care Home Version 5.0 Page 24 the event of a fire. 24 YA42 23(4)(e) A fire drill must be conducted to include service users and records maintained within the home. Data sheets must be completed for each COSHH product used within the home. 01/02/06 25 YA42 13(4)(c) 01/02/06 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 Refer to Standard YA6 YA17 Good Practice Recommendations Consideration should be given to the presentation of service users plans to make them more accessible to each person, based on their communication needs. Consideration should be given to including service users in drawing up the weekly shopping list to promote their skills in this area. Petersfield Care Home DS0000017053.V263375.R01.S.doc Version 5.0 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. 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