Inspection on 27/06/06 for Primrose House

This inspection was carried out on 27th 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Primrose House 18/06/08

Primrose House 03/07/07

Primrose House 09/02/06

Primrose House 28/06/05

Primrose House 25/11/04

Primrose House 20/04/04

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 Primrose House 2 Moor View Western Road Ivybridge Devon PL21 9AW Lead Inspector Wendy Baines Unannounced Inspection 27th June 2006 10:00 Primrose House DS0000003780.V291795.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 Primrose House DS0000003780.V291795.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. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primrose House Address 2 Moor View Western Road Ivybridge Devon PL21 9AW 01752 894222 NONE 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 C A Nurse Mrs C A Nurse Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2006 Brief Description of the Service: Primrose House is a small care home registered for five younger adults with a learning disability. The home provides a service primarily for people with autism and Aspergers syndrome. The emphasis is on a homely atmosphere where service users can be as independent as possible while being supported within a safe and caring environment. Service users are included in the daily domestic routine of the home and are encouraged and supported to voice and express their views and concerns. Primrose House is a large terraced house in the centre of Ivybridge village, which is located ten miles to the east of central Plymouth. Service users accommodation is spread over two floors. The home does not have appropriate facilities for potential service users with significant physical disabilities. The house has a large garden to the rear. The location of the home allows service users to walk to local shops and amenities and enjoy a lifestyle that minimises restrictions but provides support and guidance as necessary. The registered provider, Mrs Cheryl Nurse, has owned and managed the home for the past eight years. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is a summery of a cycle of Inspection activity at Primrose House since the last inspection visit. To help CSCI make decisions about the home; documents submitted since the last inspection were examined along with the previous inspection report, two site visits totalling 10 hours were carried out with no prior notice being given to the home as to the date and timing, discussions were held with the manager and staff on duty, various records were sampled such as care plans and risk assessments. A Pre-inspection questionnaire was sent to the manager and individual questionnaires were given to staff that work at the home, however this information was not returned. A tour was made of the home and garden, time was spent with the people who live in the home both individually and in groups with staff. In addition a sample group of residents were selected and their experience of care was ‘ tracked’ through records and discussion with staff and management from the early days of their admission to the current date, looking at how well the home understands their needs, and the opportunities and lifestyle they experience. Time was then spent with these residents and questionnaires were sent to their Care Managers and family where appropriate. Questionnaires returned by two relatives indicated that they are satisfied with their experience of the home and the care provided. Feedback from the local Learning Disability Services included; ‘‘ I am impressed by the caring attitude of staff who hold the residents as the top priority’’ This approach hopes to gather as much information about what the experience of living at the home is really like, and to make sure that residents views of the home forms the basis of the report. What the service does well: Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 6 Primrose House is a small care home situated within the close- knit community of Ivybridge in the South Hams. The location of the home allows service users who wish to develop their skills and independence to access facilities in the community with minimal support from staff. Some service users attend local day services, which are within walking distance of the home and all service users use local shops and leisure facilities. Service users are of a similar age and are encouraged and supported to lead an active and fulfilled lifestyle. Staff demonstrate a good awareness of service users rights and work hard to support and encourage them to make choices about their daily routines. Due to the small size of the home staff are able to monitor any changes in service users health and make relevant referrals and contact with specialist Learning Disability Services when required. Feedback from a Specialist Learning Disability consultant involved in the home included; ‘ the home provides a relaxed and homely atmosphere, whilst providing good support and monitoring of any difficulties’’ What has improved since the last inspection? What they could do better: Staff must have a good understanding of issues relating to Adult Protection. The home must have clear procedures for staff to ensure that they know what to do if they suspect an incident of abuse has occurred. These procedures must Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 7 be in line with locally agreed protocols. Therefore staff should attend Local Multi-agency Adult Protection training. The homes Policies and procedures must include a Lone working Procedure, which should detail contact numbers and procedures to follow in the event of an emergency. The Registered Provider must ensure that service users are supported by appropriately trained and skilled staff. Staff training records and training records must be in place, which reflect the needs of the individuals within the service. The Registered Provider must provide evidence that training is undertaken and kept regularly updated. The home should develop a quality assurance system that focuses on quality of life outcomes. 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. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 8 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 Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. This judgement has been made using available evidence including a visit to the home. The homes admissions procedures ensures that service users are able to be involved in making a choice about where they live and the services they receive. EVIDENCE: A Statement of Purpose and service user guide have been combined into one document. This is available to existing and prospective service users. The home has had no new admissions since the last inspection. The Registered manager confirmed that in the event of a new admission an assessment would be completed with arrangements for visits to the home when possible. Previous admission records confirmed this information. One service user spoken to said that they had been able to visit the home prior to moving in and had been able to establish that Primrose House would be a good place to live ‘ with staff that understand my needs’. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 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): 6,7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home now has a more clear and consistent care planning system in place, which provides staff with the information they need to satisfactorily meet service users needs. EVIDENCE: A sample of service user plans and records were seen during the inspection. Since the last inspection care plans and guidelines available to staff have been further developed and include detailed information about each individuals needs and how care should be delivered. This information confirmed that service users have been involved in making decisions about the support they receive and this information is regularly reviewed and updated. Staff demonstrated a good understanding of the communication methods of each individual. This knowledge and understanding is used to ensure that service users are supported adequately to make decisions and choices about their day- to- day life in the home. Two service users had their own daily planners, which included a range of signs, symbols and pictures to detail daily Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 11 events and planned activities. Staff spoken to recognised the importance of this information for service uses that require clear information and consistency. Discussion took place with the manager for the need to include details of each individual’s communication methods within the service user care plan. Since the last inspection care plans have been developed to include risk assessments for each area of care. Where risk assessments have been completed this information should be signed, dated and reviewed as part of the care plan process. Through discussion, observation and case tracking it was evident that service users are encouraged to be as independent as possible. Staff were observed offering advice and guidance to service users about how to keep safe before they left the house, and some service users had attended specific skills courses where risks had been identified. Service users are encouraged to manage their finances as much as possible. All service users have their own bank account and a record is kept by the home of all expenditure. Service user files are kept locked away. The home is in the process of extending the property to include a staff office. This facility would be beneficial to the home and would improve the confidentiality and privacy of service users information. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 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): 11,12,13,14,15,16. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Service users are encouraged and supported to develop their skills and independence. They can enjoy a range of stimulating and meaningful activities inside and outside the home. EVIDENCE: Primrose House is located within easy access to the shops and facilities in the small community of Ivybridge. Most of the service users currently living in the home are able to access opportunities outside the home with minimal support. The atmosphere in the home was warm and welcoming, service users were either getting ready to go out for the day or having a relaxing breakfast and chat in the dining room. Some service users attend local day centres and colleges, and all use the local shops and leisure facilities. Most service users are well known in the local community and have been able to use local services and support networks to further enhance their independence. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 13 Each service user has their own interests, which are encouraged and supported by the staff. These include; shopping, cycling, swimming and visiting friends and family. This information was documented within care plans and on individual weekly planners. It was evident through discussion with service users that they consider Primrose House as their home and consider their daily chores and tasks as very important. One service user had picture/symbol instructions to support the use of the washing machine and tumble dryer. Staff spoken to said that there were no restrictions regarding visitors although everyone would be expected to consider the rights and feelings of everyone in the home when making these arrangements. Feedback from family members regarding their experience of the home and the care provided was positive. The Registered manager and staff are very aware of the rights of service users and promote their decision- making skills with regard to financial and other personal matters. This awareness was reflected in the daily records, which demonstrated an awareness of issues relating to rights, dignity and respect. Service users bedrooms have locks and individuals are able to choose whether they want to spend time alone or in the company of others. Service users participate in activities individually and are also able to choose an outing with the other service users at the weekend. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 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): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The health needs of service users are well met with evidence of good multidisciplinary working taking place on a regular basis. EVIDENCE: Current service users are able to attend to most daily personal care tasks with minimal support. Discussion and records confirmed that they may need prompts, guidance and reminding of issues relating to personal hygiene. Service users choose their own daily routine, shop for their own clothing and make decisions regarding their appearance. Staff will give advice and assistance when asked. Daily records confirmed that service users are supported and encouraged to attend routine health checks, and use local facilities where possible. Since the last inspection service user records and care plans have been developed and organised and are now more detailed and accessible to those providing care. Health needs are monitored and referrals made to specialist health services when necessary. Feedback from a Specialist Learning Disability consultant confirmed that the home makes referrals as soon as a problem or change in health has been identified and provides ‘ excellent information’ regarding the individual concerned. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 15 The Proprietor and manager for the home said that she has been very frustrated by the lack of response by some external agencies regarding what the home considers as serious health issues. Advice was given for the home to liaise with the Adult Protection Team if it was felt that this lack of response placed an individual at risk. The homes medication procedures were inspected and records were found to be accurate and complete. Medication was stored safely. Where possible service users are encouraged to self- medicate and for these individuals risk assessments had been completed and sufficient storage and recording procedures were in place. All service users are encouraged to have some involvement in arrangements concerning their medication and this may include going with staff to collect prescriptions from the chemist. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 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): 22,23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Staff have not received sufficient training relating to the protection of vulnerable adults. Care plans and service user records provide sufficient information to enable staff to meet the needs of service users with difficult and sometimes challenging behaviours. EVIDENCE: No complaints have been received by the CSCI or the home since the last inspection. It was very obvious through observation that service users are very involved in discussions regarding the home and their care and most are able to voice their views verbally. Staff demonstrated a good understanding of each individuals communication methods and were able to respond promptly and sensitively to none verbal forms of communication. Service users spoken to said that they would know who to speak to if they had a problem and felt that all the staff would listen to them. Staff spoken to were aware of different forms of abuse but had not received sufficient training relating to the Protection of Vulnerable Adults and locally agreed procedures for dealing with incidents of abuse. The home did not have clear guidelines for staff about what to do if they are informed of or suspect an incident of abuse. Since the last inspection the home has developed and improved care plans and records relating to each individual service user. Information was available Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 17 regarding specific behaviours, and where service users may be aggressive towards themselves or others. The manager said that she has also spent time speaking to each member of staff to ensure that they understand this information. Records did not evidence that all staff undertake regular training relating to these specific care needs. The home had written policies and procedures relating to the handling of service users money and all financial records were found to be in good order. Care plans included information regarding service users money skills and the type of support required. Where a risk had been identified in this area of care the details of the risk and how to manage it had been documented. Staff were observed supporting service users to attend to daily tasks independently whilst offering advice and guidance on keeping safe, health and happy wherever possible. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Service users live in a safe, comfortable, clean and well-furnished home. EVIDENCE: The house is bright and spacious, and room sizes are adequate for the number of service users accommodated. There is an attractive garden and patio area at the rear, which is used in the summer for BBQs. All service users rooms were seen and these were decorated to reflect individual taste and personality. Locks were provided on bedroom doors. Staff use the lounge area for ‘ sleeping-in’ duty, which could restrict service users use of this room during the night. Building work had started to extend the kitchen area, which the manager said would create an office/sleeping-in room for staff. All parts of the house were found to be clean and hygienic. Primrose House DS0000003780.V291795.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): 31,33,34,35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Staffing levels are regularly reviewed and adjusted to meet the needs of all service users living in the home. Procedures are not clearly documented for when staff are working alone. It is not evident that all staff undertake regular training relating to the needs of the people they are supporting. The standard of vetting and recruitment practices in the home are not sufficient, and could potentially leave service users at risk. EVIDENCE: Since the last inspection the Proprietor and Registered manager has reviewed the staffing levels and recruited one care worker. Discussion with the manager and details provided on the rota confirmed that two members of staff are always on duty during the busy times of the day (mornings), and when all service users are at home. As most service users are able to go out independently staffing levels are increased dependent on the activity or assessed needs of the individual as agreed with Social Services. Two staff are also on duty at weekends. The rota confirmed that there are times when staff are working on their own and discussion took place with the manager for the need to ensure that Lone working procedures are in place with clear information about contacts and what to do in the event of an emergency. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 20 Staff demonstrated a good understanding of service users needs and since the last inspection the recording of this information has significantly improved, which will further ensure consistency and continuity of care. Staff records did not evidence a training plan, which reflected the needs of the individuals in the service. Some of the staff spoken to said they had attended training courses but this had not in all cases been documented or evidence that staff training was updated. Four staff files were seen during the inspection and these included details of staff who had worked in the home for a number of years and those more recently appointed. It was evident that the Proprietor advertises locally for staff and often appoints people that she has some prior knowledge of. However, application forms had not been completed and references for recently appointed staff had not been requested. CRB checks had been completed for all staff working in the home. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Service users and staff have access to the Proprietor who provides an informal and open style of management. The Proprietor and Registered Manager has demonstrated an awareness of the areas in which the home needs to improve and has been well supported by senior staff to address the requirements and recommendations from the previous inspection. EVIDENCE: Primrose House is a small care home, which is owned and managed by Mrs Cheryl Nurse. Mrs Nurse has a nursing qualification and has had many years experience of working with adults with a Learning Disability, particularly those with Autistic Spectrum Disorders. Mrs Nurse does not as yet hold the Registers Managers award, or an equivalent management qualification. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 22 Throughout the inspection service users were observed as being comfortable and relaxed within their home and were able to go about their daily routines independently or with help from staff when requested. The manager and staff had given much consideration to the issues raised at the last inspection and have worked hard during the last 6 months to address these issues and meet the standards. The Registered Provider must ensure that the homes recruitment procedures are robust and evidence that staff have sufficient skills and training to meet the needs of service users living in the home. Senior staff have worked hard to develop care plans and service user records and have spent time with the staff team to ensure that they understand this information. It was evident that the home regularly liaises and consults with service users, family and other agencies about specific situations and care issues. However, the home does not have a system for gathering this information as a means of analysing the quality of the service or outcomes for individuals. The homes Fire log was seen and all staff were due to attend updated Fire Training. Since the last inspection risk assessments had been completed for; hot surfaces/water, and window restrictors. This information must be signed, dated and reviewed. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 2 X X 3 X Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation 18 Requirement The Registered Provider must ensure that all staff are aware of what to do if they are informed of or suspect that an incident of abuse has occurred. The homes policies and procedures relating to Adult Protection must include contacts and locally agreed guidelines for dealing with these incidents. A policy and procedure must be in place, which covers ‘ Lone Working’ This would need to include contact numbers and what staff need to do in the event of an emergency. 2 YA34 18 The Registered Provider must 01/10/06 ensure that appropriately trained and skilled staff supports service users. Staff training records and training plans must be in place and reflect the needs of the individuals within the service. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 25 Timescale for action 01/10/06 The Registered Manager must evidence that training is undertaken and kept regularly updated. 3 YA35 Schedule4/ The Registered Provider must 01/10/06 19 ensure that the Recruitment procedures in the home are robust and protect service users. A full application form should be completed and include gaps in employment history. Staff should not be in post prior to the receipt of two written references. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA23 YA37 YA39 Good Practice Recommendations The Registered Provider should ensure that senior staff and if possible all staff have attended the multi-agency Adult Protection training. The Proprietor should obtain the Registered Managers award. The home should have a quality assurance system in place, which includes feedback from service users, family, advocates and other agencies- this should focus on the quality of life outcomes for service users. Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Primrose House DS0000003780.V291795.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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