Inspection on 10/09/07 for Rafael

This inspection was carried out on 10th September 2007.

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

Other inspections for this house

Rafael 19/06/06

Rafael 09/01/06

Rafael 24/08/05

Rafael 02/11/04

Rafael 24/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Rafael 172 Stanley Park Road Carshalton Beeches Surrey SM5 3JR Lead Inspector Barry Khabbazi Key Unannounced Inspection 10th 20 of September 2007 08:30 th Rafael DS0000038904.V348965.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 Rafael DS0000038904.V348965.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. Rafael DS0000038904.V348965.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rafael Address 172 Stanley Park Road Carshalton Beeches Surrey SM5 3JR 020 8296 1016 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) jan_farrar@hotmail.co.uk Angel Home Limited Mrs Janice Nichol Farrar Care Home 3 Category(ies) of Learning disability (0) registration, with number of places Rafael DS0000038904.V348965.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th June 2006 Brief Description of the Service: Rafael is a residential care home providing care for up to three adults between the ages 18 and 65 years in the category learning disability. There are currently three service users living at the home. The premises are on Stanley Park Road, which is busy through-route between Wallington and Sutton. It is within walking distance of local shops and transport links. It comprises three single bedrooms, a lounge, a dining room, kitchen, storeroom, bathroom, two toilets plus an office on the second floor. There is a large garden to the rear and a small front area with off-street parking for two cars. The three single bedrooms have been equipped and decorated to National Minimum Standards and include suitable furniture and fittings and décor, but no ensuite facilities. Fees start from £560. Rafael DS0000038904.V348965.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key Standards identified throughout this report were all assessed at this inspection. Additional non key Standards were also examined where shortfalls were identified under those Standards. As the service users use the local community well, there were no service users present on the first day. As a result of this a second short visit occurred to meet the service users and observe staff interaction with them. This inspection was unannounced. During this inspection breakfast and staff interaction with the service users was observed. The manager was interviewed. Records, care plans and the building were examined, as were the residents’ bedrooms. Although a few minor shortfalls in meeting the National Minimum Standards were identified, no serious concerns were raised as a result of this inspection. See the requirements page and ‘what the home could do better’ section for details. A number of good practice examples were also identified and are recorded in the ‘what the home does well’ section of this report. The home was found to be generally well run and service users said they were happy at the home. There was a calm and relaxed atmosphere in the home and the staff were seen to treat the service users with kindness and respect. What the service does well: Additional mini reviews occur in addition to the required 6 monthly reviews. This ensures changing needs are quickly identified, recorded and made known to staff. Residents are weighed monthly if they agree to this. This ensures that the associated health issues are quickly identified and addressed. Although funding for holidays still needs to be provided by the placing authority, the home has ensured all the service users have a holiday from the home’s own funds. The small size of the home facilitates staff and residents knowing each other well and care therefore is only provided by staff that are well known to the residents. The communal areas exceed the national minimum size standard. This provides more space for the residents. Rafael DS0000038904.V348965.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. Rafael DS0000038904.V348965.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 Rafael DS0000038904.V348965.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): Standards 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides all of the information needed for potential new residents and their relatives, and care managers, to make an informed decision about moving in to the home. EVIDENCE: There has not been a new placement made since the last inspection. A new placement will need to be made before Standard 2 can be fully reassessed. It was therefore not possible to re-assess Standard 2 fully at this time. However, this Standard was previously assessed as met and will remain so until the Standard can be re-assessed. Rafael DS0000038904.V348965.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): Standards, 6, 7, and, 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ assessed needs, and how the home meets these needs, are not fully and clearly recorded in care plans. This could affect the home’s ability to meet all of a resident’s needs. Residents are supported to make decisions about their lives. Residents are not always appropriately supported to take risks as part of their independent lifestyle, as risk assessments do not contain all the information required to facilitate minimising restrictions of liberty for the residents. EVIDENCE: Care plans are recorded over many documents and, somewhat confusingly, the initial assessment is also called a care plan. These documents when combined still did not cover many the elements required under Standard 6, for example religious and cultural needs. Rafael DS0000038904.V348965.R01.S.doc Version 5.2 Page 10 In addition, their purpose of providing clarity and communicating a resident’s needs efficiently to staff can not be met by so many documents spread over a whole file. The following requirement and 2 recommendations are now set to address this shortfall: Requirement: Care plans must contain all the elements required under Standard 6. Recommendation: the numerous care planning information documents should be condensed into one simple ‘care plan’ form stating all needs of a resident and how they are to be met. Recommendation: The assessment document should have its name changed from care plan to initial assessment for clarity and efficiency. It has been noted that as this is a small home and staff should therefore already know a resident and their needs, that this shortfall may not have a negative impact on the residents unless new or agency staff are used. Reviews were examined and are occurring with at least the required frequency. Good practice identified at this inspection: Additional mini reviews occur in addition to the required 6 monthly reviews. This ensures changing needs are quickly identified, recorded and made known to staff. Service users are supported to make choices and decisions in their lives. On the second morning one service user stated that he had made choices regarding his dental health care and another was seen being supported to make choices regarding meals for the day. The home has a key worker system. The residents are offered the opportunity to participate in the day to day running of the home through regular meetings and individual discussions with their key workers. Part of the role of the key workers at the home is to ensure the service user’s individual opinions are put forward. Regular service user meeting are held and service users are encouraged to attend. Notes are taken of each meeting and placed in communal areas. The service users at the home also produce a newsletter with details of recent events at the home. Risk assessments were present for health and safety purposes but not for some restrictions of liberty, for example, locking residents in the home by locking the front door and residents not having a key for this. In addition, where restrictions of liberty are needed to protect the resident, other options or training have to be explored to avoid the restriction of liberty. The following requirement is now therefore set. For any pre planned restrictions of liberty or pre planned restraints {Cot sides, locked doors etc}, risk assessments must contain all the information required under Standard 9.4, and in particular, details of how training and other options have been explored and the involvement of relatives or independent advocates. Rafael DS0000038904.V348965.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): Standards, 12, 13, 14, 15, 16, and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to be a part of the local community and are able to take part in appropriate activities. Residents are well supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Service users rights are now better respected and responsibilities recognised in their daily lives. Residents are offered a healthy diet and have choices in meals offered. Rafael DS0000038904.V348965.R01.S.doc Version 5.2 Page 12 EVIDENCE: The service users have the opportunity to attend religious services if they wish. The local community is well used by the residents. The local parks, cafes, cinema, pubs, libraries, bowling alley, and shops are accessed. The home arranges for service users to attend clubs. Standard 14 refers to holidays being funded by the placing authority. Although funding for holidays still needs to be provided by the placing authority, the home has ensured all the service users have a holiday from the home’s own funds. However the following recommendation is still needed here: Each service user should be offered a seven-day holiday paid for by the placing authority, as part of the contracted price. Good practice identified at this inspection: Although funding for holidays still needs to be provided by the placing authority, the home has ensured all the service users have a holiday from the home’s own funds. The house rules and daily routines are as flexible as possible, bearing in mind the weekday commitments of the service users. The service users are encouraged to choose the menus on offer and to help out with cooking and household chores. On the second day of the inspection one service user was observed to be sensitively supported in making a rhubarb crumble for the evening meal. The residents are encouraged to be as independent as possible and participate in cleaning their rooms, cooking and choosing meals and trips. Confidence is currently developed via providing a safe environment, building trust through appropriate support and safety, and through community access. Residents are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. The service users are encouraged to choose the menus on offer and to help out with cooking. Meals can be taken in the kitchen or dining room, both have room for all service users to be seated. The home menus are based on the likes and dislikes of the home’s residents. Additional drinks and snacks are available at any time. The menus examined were varied and alternatives are provided for those residents who did not want the main dish on offer. Rafael DS0000038904.V348965.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): Standards 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ physical health needs are met well by this home. This ensures that the residents’ physical health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is also well managed to ensure maximised good health. EVIDENCE: Rafael DS0000038904.V348965.R01.S.doc Version 5.2 Page 14 Personal care is provided in private, and timings of this are also flexible, for example residents can have a bath when they are not booked in for this and have been observed not being discouraged from taking their time when eating. The home provides consistency and continuity through designated key workers. Service users have access to relevant professional support to maximise independence. Good practice identified at this inspection: Residents are weighed monthly if they agree to this. This ensures that the associated health issues are quickly identified and addressed. The residents are registered with a local G.P. They are able to access community health facilities such as opticians, chiropodist and district nurses as required. Service users are supported to attend outpatient appointments and other medical appointments as required. The home has a copy of the British Medical Association guide to medication in place. Medication profiles and clear medication administration record sheets were seen in records sampled. Medication is kept securely in a locked metal cabinet. The staff team have receive training on medication and epilepsy. The home has a policy and procedure in place for the receipt, recording, storage, handling, administration and disposal of medication. All medication records were complete at the time of the inspection. Rafael DS0000038904.V348965.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): Standard 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On the whole this home manages complaints well so that service users feel their concerns are listened to. Most of the home’s policies and procedures relevant to this Standard currently facilitate protecting service users from abuse, but a wills policy would strengthen this protection. EVIDENCE: The complaints procedure was clear and contained all of the elements required to meet Standard 22 including a minimum response time of less than 28 days. There have been no complaints since the last inspection. The home has a copy of the local authority Adult Protection Policy on site. The staff team have attended training on adult protection issues and a record is kept on their files. The staff team are aware of the action they must take if they need to report an incident. Standard 23.2 requires a will policy to be present and to state that staff can not assist in the making of, or benefiting from service users’ wills The following requirement is set to address this: The home’s policies must preclude staff involvement in assisting in the making of, or benefiting from service users’ wills. Rafael DS0000038904.V348965.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): Standards 24, and 30.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building, rooms and furniture generally meet the residents’ needs and in most areas provide a comfortable and safe environment which promotes independence. The home is hygienic and clean, homely and comfortable. This environment therefore facilitates the residents’ health and emotional well-being. EVIDENCE: Each resident has their own room, which is personalised according to their own tastes and character. Individual rooms were lockable and service users can have keys to their own rooms. Master keys are only used in an emergency. Service users can chose how their rooms are decorated and had personalised their own space with their own items. The building and facilities are generally suitable for this group of residents. Good practice identified at this inspection: Rafael DS0000038904.V348965.R01.S.doc Version 5.2 Page 17 The small size of the home facilitates staff and residents knowing each other well and care therefore is only provided by staff that are well known to the residents. Good practice identified at this inspection: The communal areas exceed the national minimum size standard. This provides more space for the residents. The building was clean and tidy and rooms were generally free of offensive odours. The home gave the impression of a clean and hygienic home. The home has policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, and dealing with spillages. Laundry facilities have easily cleanable non-permeable floors and easily cleanable walls. Washing machines have appropriate programmes over 65 degrees to control risk of infection and one has a sluicing facility. The laundry room had an extractor fan and natural ventilation. Rafael DS0000038904.V348965.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): Standards, 32, 34, and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents needs are not met by appropriately qualified staff. The home’s recruitment procedures protect the residents through vigorous staff vetting. Residents needs are met by appropriately trained staff. EVIDENCE: 1 staff member has a NVQ 3, one other is working towords a NVQ3 and one other is working towords a NVQ 2. Standard 32 requires 50 of care staff to have a NVQ 2. The following requirement is set to reflect this current shortfall. At least 50 of care staff must have a NVQ 2. Rafael DS0000038904.V348965.R01.S.doc Version 5.2 Page 19 All elements of Schedule 2 {staff files} are kept securely on site and are available for inspection. This includes CRB checks, references and records of staff disciplinary action. These were inspected during the last inspection and were in order. As no new staff had started since that inspection there was no need to check recruitment files at this inspection. The Standard currently remains met. An initial induction is provided for all staff from their starting date. As there have been no new staff since the last inspection, this Standard will be examined in more detail once a new staff member starts and undergoes the required induction and foundation training. Rafael DS0000038904.V348965.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): Standards, 37, 39, 40 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. The home’s quality assurance system involves the residents and relatives, and provides feedback to them, to allow them to be involved in improvements and measure improvements in the home for themselves. Policies and procedures generally protect residents but some are still needed and some need to be also produced in a format that residents can access. The health and safety and welfare of the residents is promoted and protected in most areas except in the case of the hot water system. EVIDENCE: Rafael DS0000038904.V348965.R01.S.doc Version 5.2 Page 21 The manager was observed to have a good relationship with the service users and was observed to provide support with sensitivity. The manager has management experience and is currently undertaking the Registered Managers Award. A requirement is technically needed here: The manager must complete the Registered Managers Award. Standard 40.4 requires relevant policies to be also available in formats that are accessible to the service users. The new wills policy required under Standard 23 would fit into this category, as would other policies like access to files. The following requirement is now set to address this: Service users must have access to relevant policies and procedures, and in an accessible format. For example, access to files, and money management policies. The home has the required Quality Assurance tools which are structured into a Quality Assurance system that makes the service users central to the process. Inspection reports, service manager inspections, complaints, residents’ meetings, and relative and service user questionnaires are used to gather Quality Assurance information. The home also ensures that the annual development plan is influenced by the above quality assurance information gathering tools, and that where relevant information from these tools is included in the annual development plan. This is then made open to the service users, to allow measurement of achievement in improving quality, by presenting the findings and annual development plan to the residents in one specific residents’ meeting per year. All of the health and safety policies and procedures relevant to this standard were seen to be present. Moving and Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. Control Of Substances Hazardous to Health policies and data sheets were present and all these items are locked away securely. An asbestos survey had occurred in line with the current asbestos at work regulations. The testing of systems required in Standard 42 were also present and inspected. These included fire fighting equipment testing, emergency lighting, Portable Appliance Testing, Boiler and gas testing. The home does not have thermostatic mixer valves but sets the boiler at a lower temperature instead. This does not meet the standard as the tank needs to be set hotter to kill any bacteria in the system, and then only cold at the tap to prevent scalding. The following requirement is now therefore set: Rafael DS0000038904.V348965.R01.S.doc Version 5.2 Page 22 The manager must risk assess the urgency of fitting a thermostatic mixer valves and implement the findings of the risk assessment. Rafael DS0000038904.V348965.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 1 2 3 4 5 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 4 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x 3 x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 3 2 x 2 x Rafael DS0000038904.V348965.R01.S.doc Version 5.2 Page 24 no 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 2. Standard YA6 YA9 Regulation 15[1] 13(7) Requirement Care plans must contain all the elements required under Standard 6. For any pre planned restrictions of liberty or pre planned restraints {cot sides, locked doors etc}, risk assessments must contain all the information required under Standard 9.4, and in particular, details of how training and other options have been explored and the involvement of relatives or independent advocates. The home’s policies and practices must preclude staff involvement in assisting in the making of or benefiting from service users’ wills. At least 50 of care staff must have a NVQ 2. The manager must complete the Registered Managers Award. Service users must have access to relevant policies and procedures, and in an accessible format. e.g., access to files, complaints, etc. The manager must risk assess the urgency of fitting a thermostatic mixer valves and DS0000038904.V348965.R01.S.doc Timescale for action 01/11/07 01/11/07 3 YA23 12[1]a 01/11/07 4 5 6 YA32 YA37 YA40 18[1] 9[1]i 12[4]b 01/04/08 01/04/08 01/04/08 7 YA42 12[1]a 13[4]abc 01/11/07 Rafael Version 5.2 Page 25 implement the findings of the risk assessment. 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 YA14 YA6 YA6 Good Practice Recommendations Each service user should be offered a seven-day holiday paid for by the placing authority, as part of the contracted price. The numerous care planning information documents should be condensed into one simple ‘care plan’ form stating all needs of a resident and how they are to be met. The assessment document should have its name changed from care plan to initial assessment for clarity and efficiency. Rafael DS0000038904.V348965.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Rafael DS0000038904.V348965.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. 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!