Inspection on 16/10/07 for Proctor Residential Home Ltd

This inspection was carried out on 16th October 2007.

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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Proctor Residential Home Ltd 11/11/08

Proctor Residential Home Ltd 28/11/06

Proctor Residential Home Ltd 09/05/06

Proctor Residential Home Ltd 20/01/06

Proctor Residential Home Ltd 27/09/05

Proctor Residential Home Ltd 12/01/05

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

CARE HOME ADULTS 18-65 Proctor Residential Home Ltd 40 Filton Avenue Horfield Bristol BS7 0AG Lead Inspector Sandra Jones Key Unannounced Inspection 16th October & 23rd November 2007 09:30 Proctor Residential Home Ltd DS0000062466.V348848.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 Proctor Residential Home Ltd DS0000062466.V348848.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. Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Proctor Residential Home Ltd Address 40 Filton Avenue Horfield Bristol BS7 0AG 0117 9354403 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) Proctor Residential Home Ltd Mr Michael Edward Kendall Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 5 persons, 2 of whom can be 65 years and over 28th November 2006 Date of last inspection Brief Description of the Service: Proctor House is a care home providing personal care for five service users aged between eighteen and sixty four years. The home is situated in a suburban area, and located on a bus route that gives access to local shops, leisure and other amenities. The home is in keeping with the local neighbourhood. The home has undergone re-registration with the Commission for Social Care Inspection as the business has moved from a sole trader to a limited company. In addition the manager of the home has changed from Mrs Kendall to Mr Kendall (the son). Mrs Kendall remains the provider. The home primarily provides personal care to service users with a mental disorder. It is a quiet home that would best be suited to those who prefer a quieter lifestyle. Fees range from £600.00 - £1000.00 per week. Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted unannounced over two days in October and November 2007 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from individuals and staff. The Annual Quality Assurance Assessment (AQAA) was sent to the home for completion, with “Have your Say” surveys for people at the home, their relatives and social and health care professional. The manager returned the AQAA and two surveys from the people at the home. Feedback was received through the survey from two health care professionals. Prior to the visit some time was spent examining documentation accumulated through reports, surveys and the AQAA. This information was used to plan the inspection visit. The five living at the home were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the manager, staff and people using the service were gathered through face- to- face discussions. What the service does well: The GP said through the comment card “ I never cease to be impressed by the care that Mrs Kendell and her family give to the people at the home.” One visitor said that the staff maintain a quite and calm environment, which suits her relative. The AQAA completed by the manager states that giving people choices created through meals, activities and empowerment is what the service does well. It is evident that repairs and improvement to the property continue to provide a homely environment for the people living at the home. Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Proctor Residential Home Ltd DS0000062466.V348848.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 Proctor Residential Home Ltd DS0000062466.V348848.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. JUDGEMENT – we looked at outcomes for the following standard(s): (2) Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. The Statement of Purpose must be reviewed to reassure individuals that the home has the resources and staff have the skills to meet the needs of people wishing to live at the home. The arrangements for admission to the home must be developed to ensure that only those individuals whose needs can be met are admitted to the home. EVIDENCE: “Have your say” surveys were received from two individuals living the home. One person said that they were asked if they wanted to move to the home and the other person said they were not asked. One person was admitted to the home since the last visit and social workers needs assessment was provided by the Mental Health team. It is evident from the documentation that the needs of this person can be met at the home. There is a prepared admission procedure that confirms introductory visits are encouraged prior to the admission. Requests for admission are predominately from the Local Authority and social workers needs assessments are provided before admission. However, the requirement to review the Admission procedure has not been actioned and is repeated through this inspection visit. Proctor Residential Home Ltd DS0000062466.V348848.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. JUDGEMENT – we looked at outcomes for the following standard(s): (6), (7)&(9) Quality in this outcome area is (poor) This judgement has been made using available evidence including a visit to this service. The people that live at the home can expect sensitive and prompt support from a skilled staff team, the home fails to evidence that it provides a consistent service because of omissions in the care planning system. Risk assessments must be conducted to ensure that where possible the level of risk to the person is lowered. EVIDENCE: Individuals at the home with health care professionals and staff attend Individual Care Programme Approach (ICPA) meetings convened by the mental health care team. Home care plans were reviewed recently and it is evident that the format has been changed. Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 10 Through Proof of competency checklists the manager conducts assessments that are based on the person needs, with mobility smoking, leaving the premises and personal care. Using electrical equipment, medications also form part of the assessment, with additional space for comments. Where a need is identified through the checklist, members of staff record the actions to be taken. A care plan is then devised from the checklist, which includes the assessed need, goals and action to be taken by the staff. While competency checklist assesses all areas of need and care plans describe the actions to be taken, a person centred approach to meeting needs must be adopted. The member of staff on duty said that they are expected to develop care plans and to discuss the care plans with the person and reach agreements about the action plans. Where individuals exhibit aggressive and violent behaviours, a record of mood indicators is kept. It is acknowledged that the indicators provide an overview of the person needs. However, strategies must be developed from the indicators to make the process effective to consistently diffuse and divert aggressive and violent behaviours. Individuals at the home have mental health care needs and care plans must detail the triggers of deterioration of their mental health and the actions to be taken by the staff. People living at the home communicate verbally and the manager said they are able to make decisions about all aspects of their care. Activities that involve an element of risk and documentation show that for some individuals records that identify potential risks are in place. However, they are not dated and not signed. For one person risk assessments are not in place and it is clear that there are high levels of risk to the property and others. An Immediate Requirement was issued for the manager to develop risk assessments for this person. Risk assessments were received within the timescale and must be reviewed. The home’s Accident policy states that an accident form will be completed whenever individuals are involved in an accident. Proctor Residential Home Ltd DS0000062466.V348848.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. JUDGEMENT – we looked at outcomes for the following standard(s): (12), (13), (15) & (17) Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. Support systems will be developed for individuals to lead active and interesting lifestyles and to be valued members of the community. EVIDENCE: The manager intends to revert to the previous arrangements for social activities, education and occupation and not to follow the recommendation to incorporate the information into the care planning process. The manager said that people at the home will be better stimulated because at present people are isolated. The people at the home recently attended a concert and will be attending others during the Christmas period. One person consulted described the activities undertaken, which are mainly watching the television, reading and walking. This person also said that they are times when they are bored. Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 12 The people at the home are independent within the community and do not need the support from staff. One person giving feedback said that they are independent in the community and do not need staff support outside the home. Visitors at the home are welcome and the manager said that with the exception of one, the people at the home receive visitors. The visitor’s policy is included within the Terms and Conditions of residency at the home. There is a visitor’s book and there is an expectation that visitor’s records the date and nature of their visits. A visitor at the home during the inspection said that the staff welcome visitors and staff will explain behaviours. This individual also said that contact is usually maintained by phone. The home operates within firm boundaries, which are defined within the contract of the home. The rules are listed to ensure that people wishing to live at the home can make decisions about living at the home. A person giving feedback described the rules of the home, which are based on respecting the rights of the people at the home. The manager said that members of staff are inducted to respect people at the home. Principles of care that include privacy and dignity are described within the Statement of Purpose. The way individuals rights are respected in terms of Privacy and Dignity is specified. Menus are varied and include cultural dishes to meet the diversity needs of the people at the home. The records of meals provided show that individuals at the home have choices of meals at each mealtime. One person giving feedback said that the meals are satisfactory and sufficient in quantity. Proctor Residential Home Ltd DS0000062466.V348848.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. JUDGEMENT – we looked at outcomes for the following standard(s): (18), (19) & (20) Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. Individuals can expect sensitive and prompt support for their personal and health care needs from a skilled staff team. Medication systems must improved to ensure there are safe systems of medication EVIDENCE: The service provider said that individuals at the home require some supervision but mainly undertake their own personal care. It was also stated that one person has continence needs and care plans give guidance on the actions that staff must take to meet the need. Individuals at the home are registered with a local GP and the manager said that staff accompany individuals on hospital appointments and health care visits. Staff maintain a record of multidisciplinary visits, which show that individuals health care is monitored, and where necessary referrals for specialist support is sought. Individuals at the home have input from psychiatrists, district nurses and Community Outreach Team. Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 14 There is also access to local NHS facilities and the manager said that optician visits are arranged annually and dental appointments are made as required. One person giving feedback said that they are accompanied on hospital appointments and GP’s visits. The member of staff on duty confirmed that individuals are accompanied on health care visits. This staff also explained that reports of outcome of visits and handovers ensure that advice is passed on, so that medical instructions are consistently followed. “Have your say from the GP states that the home always meet the individuals care needs. Medication profiles are in place for three people and list medications prescribed, their purpose and side effects. However, profiles for two people are missing. Medication profiles must be in place for individuals that have regular prescribe medications and, this will ensure staff’s awareness of individuals health care needs. Medication is administered through a monitored dosage system and the records cross-reference with medications held. Records show that staff sign the records of administration after administering medications and use the appropriate codes. A record of medications no longer required is maintained which the pharmacist signs to indicate receipt of the medication for disposal. Proctor Residential Home Ltd DS0000062466.V348848.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. 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 this service. Individuals can expect their concerns to be listened to and to be protected from abuse. EVIDENCE: The manager said that the people at the home are able to read and understand the current Complaints procedure and copies of the policy are provided. One person giving feedback said that the service provider would be approached with complaints. “Have your say” surveys were received from two people living at the home. One person said that they know how to make a complaint and the other that they didn’t know. The manager said that there are three people who have the potential to be violent and aggressive. It was confirmed that physical restraints are not used at the home and, members of staff are instructed to contact the police. The manager and service provider have attended Safeguarding Adults training and there are no outstanding referrals. One member of staff on duty said that they were waiting for a date to attend external Safeguarding Adults training. Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (24) & (30) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home is well maintained so individuals benefit from living in a comfortable and clean environment. EVIDENCE: Proctor House is a terrace property in a residential environment and has the appearance of a domestic dwelling arranged over three floors. The ground and first floor are used by individuals living at the home, with bedrooms and shared space on each floor. The property is close to shops, amenities and bus routes, which are used regularly by the people at the home. Bedrooms are single and the opportunity was taken to view a number of bedrooms. It was noted that bedrooms are lockable and individuals have a lockable facility in their rooms. There is a hand washbasin, adequate floor covering, nurse calls and a radiator in each room. Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 17 The furniture and fittings are provided by the home and personal belongings reflect the personality of the person. A full bathroom is located on the first floor and a shower and toilet on the ground floor. The ratio of bathrooms and toilets are less that three people sharing. This is above the National Minimum Standards of three people sharing. There is a sitting/dining room, conservatory and visitors’ room. The combined seating and dining room has seating for four people and dining space for four people. The conservatory is used as a designated smoking area with additional facilities for making light snacks and refreshments in the future. The visitor’s room is accessible to residents and used for private visits. The laundry area is adjacent to the kitchen and has the washing machine and a locked COSHH cabinet. The floor covering and painted walls ensures easy cleaning. The washing machine is domestic and has can reach 95 degrees C. Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (34) & (35) Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. Specific training that relate to the needs of the people at the home will ensure that a competent, qualified and skilled staff team supports individuals. EVIDENCE: The home’s recruitment process was assessed during this inspection. One person was recently employed through an overseas agency and personnel records for five staff were examined. Application forms, two written references and Criminal Records Bureau (CRB) disclosures are kept. The requirement to review application forms to ensure that only people suitable to work with vulnerable adults are employed, was not actioned. This requirement is therefore repeated through this inspection. One person giving feedback said that the staff were “OK”. “Have your say” surveys from the people at the home state that the staff usually act on what they say. Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 19 Training records were examined and certificates show that one person has completed the Common Induction Programme and another is undertaking inhouse induction. Members of staff have undertaken statutory training in Health & Safety, medication and First Aid. The manager said that the most recently employed member of staff has not undertaken all the statutory training and will be attending Food Hygiene and Health and Safety training in the New Year. It was further stated that members of staff would be attending Mental Health training. Two staff are various level of NVQ level 2 training. The member of staff on duty said that training is encouraged and had attended external induction and Food Hygiene training. Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (37), (39) & (42) Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. A safe environment must be provided and there is evidence that the home is subject to ongoing monitoring. EVIDENCE: The manager said that he endeavours to use a direct approach and to take staff issues into account. One “Have your say” surveys from individuals state that the staff treat them well and another said it was usual. One person giving feedback said that are respectful. The member of staff on duty said that the manager is approachable and listens to their suggestions. Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 21 Regarding consistency of care, the manager said that supervision with the staff is used to ensure that the standards of care are maintained. The member of staff on duty confirmed that individual supervision takes place three monthly with the manager. The rota in place shows that one person, the manager and the service provider are on duty throughout the day, with one-person sleeping-in at night. The manager said that the people at the home are able to manage their own finances. Fees at the home range from £600.00 - £ 1,000.00 per week. Fire Risk assessments were not available and an Immediate Requirement was issued for the manager to develop the assessments. While fire risk assessments were submitted within the timescale the quality needs improving. Fire risk assessments must be completed so that preventative measures are taken to prevent an outbreak of fire. The manager must consult with the fire officer about the way fire risk assessments are to be undertaken. The manager also ensures that the home meets associated legislation by instructing a competent person to check the gas central heating and portable appliances annually. The manager said that individuals feedback on the standards of care is sought annually through surveys. However, two people refused and one was received. Residents meetings are also used to seek feedback from the people at the home and the manager said that where necessary comments made are then discussed with the person. The manager said that future plans for the home is to continue with the decorating programme to maintain a homely environment for the people at the home. Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 2 X X 1 X Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 Requirement Care plans must be developed using the information gathered from the home and ICPA. The individual’s likes, dislikes and preferred routines must be included, along with their aspirations and personal development goals. For residents under section the action plans must define the actions to be taken for any breaches of conditions. This requirement is ongoing from 28/11/06 & 23/11/07 Members of staff must attend mental health awareness training. The recruitment process must be more robust in terms of the information sought through the application form. Full employment histories with reasons for leaving past employment and the names of two referees must be sought. (This requirement was not checked at this inspection) Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 24 Timescale for action 30/10/07 2. YA35 18(1)(c) 30/06/08 3. YA34 19 30/03/08 4. YA6 13 (6) Reactive strategies that focus on positive behaviour must be developed for residents that exhibit aggressive and challenging behaviours. Previously required 28/11/06 & 23/11/07 The Quality Assurance system must be further develop to ensure residents views are reflected into future reviews and planning for the home The Statement of Purpose must be reviewed to ensure that individuals can make choices about moving into the home. The criteria for admission at the home must be made clear. (Previously required 28/11/06 & 23/11/07) Risk assessments must be completed for activities that may involve an element of risk. Medication profiles must be developed for each person that has regular prescribed medications The manager must seek advise about fire risk assessments from the Fire Authority 30/03/08 5. YA39 24 30/12/07 6. YA1 6 30/03/08 7. YA9 13 (4) (b) 30/12/07 8. YA20 13 (2) 30/12/07 9. YA42 23 (4) 30/01/08 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 Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Proctor Residential Home Ltd DS0000062466.V348848.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!