Inspection on 18/12/06 for Redcourt

This inspection was carried out on 18th December 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

Redcourt 17/12/08

Redcourt 07/11/05

Redcourt 19/08/04

Redcourt 26/05/04

Redcourt 09/12/03

Redcourt 29/09/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Redcourt Hollincross Lane Glossop Derbyshire SK13 8JH Lead Inspector Brian Marks Key Unannounced Inspection 18th December 2006 09:00 Redcourt DS0000020081.V324410.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 Redcourt DS0000020081.V324410.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. Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Redcourt Address Hollincross Lane Glossop Derbyshire SK13 8JH (01457) 852687 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) St. Christopher`s Trust (Glossop) Limited Joan Roebuck Care Home 40 Category(ies) of Learning disability (40) registration, with number of places Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Redcourt is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories :Learning disabilities (LD) 40 The maximum number of service users to be accommodated at Redcourt is 40 7th November 2005 Date of last inspection Brief Description of the Service: Redcourt is registered to care for 40 adults with learning difficulties. However, the current occupancy capacity of the home is 37 people and there will be no further admissions until future plans for changes at the home are completed. The home was established during the 1950s by St.Christopher’s Trust, and is situated close to the centre of Glossop and its local amenities. The accommodation is made up of 2 units, separately providing accommodation for men and women. Each unit has its own laundry and some kitchen facilities although the main kitchen is still used for the main meals of the day. Additionally there is a Day Centre within the extensive grounds in which the University of Derby provides a service for residents. The Trust also supports ex-residents of the home through a registered domiciliary care agency in 3 terraced houses directly opposite and the expansion of this agency will be the mechanism for others to move on and to live more independently. The current fee for care at the home is £505 per week, paid for by statutory authorities. Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place at the home over a period of seven hours in one day. Additionally, time was spent in preparation for the visit, looking at previous reports and other relevant documents and preparing a structured plan for the inspection. At the home, apart from examining documents, care files and records, time was spent speaking to the manager of the home, who was present for the entire visit, and six of the staff working at the home at the time, including one of the assistant managers. The care records of four people who live at the home were examined but, due to their level of learning disability, only one was able to speak to the inspector about life at the home. Other residents, particularly in the men’s unit, were able to talk about life at the home in general terms. The residents present during the inspection were observed interacting with each other and being cared for by the staff on duty. In the month before the inspection St Christopher’s Trust hosted a planning workshop that looked at ideas for the future of the home, and the inspector was able to discuss the current performance of the home with professionals from the local Learning Disability Service at that time. What the service does well: The proprietors and manager have continued to demonstrate their commitment to change and modernise the home in line with current best practice and again, at this inspection visit, progress is evident and the quality of service has continued to improve. They have done this by listening carefully to what the residents want and created an open approach to planning that is professional and supportive. Local professionals have commented on the home’s staff commitment to work with other professionals to offer comprehensive services of a high quality to residents. The home’s staff have worked jointly with local social services office to complete assessments of capability of all residents and have held review meetings to plan further work. The University of Derby continues to provide practical training to residents in developing skills at the Day Centre attached to Redcourt and the multidisciplinary learning disability team and the primary care team have continued to provide high quality health care support. There is a strong commitment in the home to staff training and this is formalised by each shift having one day on a three weekly basis for staff training. Additionally a number of staff have commenced in training for a National Vocational Qualification (NVQ) which will help them move forward with the changes at the home and improve their standards of professional working. Two assistant managers have been appointed to deal with the dayto-day running of the home and this has resulted in more consistent ways of Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 6 working and in better levels of support to staff. The home’s management values its staff and they in turn have shown a high level of commitment to improving the residents’ lives. 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. Redcourt DS0000020081.V324410.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 Redcourt DS0000020081.V324410.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 good. This judgement has been made using available evidence including a visit to this service. The support and care needs of individuals are comprehensively assessed to ensure that the home continues to be right for them and that their aspirations are planned for. EVIDENCE: The majority of service users have lived in the home for many years, some since childhood. Since modernisation of the home commenced with the introduction of the National Minimum Standards, all of the residents have been subject to revised assessments of their abilities and needs which have indicated the possibility of them living in smaller community settings. In the past year thirteen ex-residents have moved into three ‘supported housing’ groups adjacent to the home as the start of a bigger programme. Staff from the University of Derby have continued their programme of assessments of skills within the day centre at Redcourt and a number of professionals from the local Learning Disability Service have been involved with individual residents during the past year and have provided further aspects of assessment activity. Additionally the programme of skills assessment has been tied together by a programme of activity by a social worker and two other community care workers during the past year and all residents will have had a review meeting by the end of this year which will indicate the range of capability and Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 9 compatibility amongst the residents. In turn this will lead to the next group of residents who will benefit from a supported living environment identifying themselves. At present no new service users are to be admitted to the home until changes to the service are implemented by the decision of the trustees. Redcourt DS0000020081.V324410.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents care needs have been assessed, risk factors identified and care planned in ways that reflect their individual preferences and abilities. Some key areas of changes in people’s lives had not been properly documented covered and their care could suffer because if this. EVIDENCE: The care records of four residents were examined in detail and they all contain a care plan that has been developed by the resident’s key worker system in consultation with them. All of the care plans examined had key areas completed which includes personal details, friendship and support details, personal history, likes and dislikes and preferred activities. Additionally they each have a ‘medical file’ that includes records of the involvement of outside professionals, incidents, accidents and other logged events. A range of risk assessments is in place but these did not always reflect changes in the individual resident, separately recorded elsewhere, such as in specific behaviour or health needs. Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 11 Additionally two of the files looked at contain a Personal Planning Book (not yet used) that will be completed as part of the development of ‘next steps’ and in particular any moves towards living in smaller settings in the local community. These documents are very resident-focussed in their design and represent a further step towards the modernisation of the service provided at Redcourt. During the past year an advocacy service has been available to the people who have moved on and this has assisted the residents to express their preferences and to make decisions about the planned changes. Within the home the manager and staff spoke about how they encourage residents to speak out for themselves as both individuals and through the group at a formal meeting. Examples given ranged from making choices about clothes to wear, leisure time and holidays to the option to move on to smaller group living. They have been assisted with the latter by being able to observe the progress of their friends who have already moved into the houses outside the home; the prospect of this holds no anxieties for the people spoken to and some expressed strong views in their wish to do so – ‘It will be a good idea for me and I can’t wait’. The extension of the range of activities available to the residents and promoting independence skills is accompanied by the recognition of risk and, as noted above risk assessments are undertaken to assist in this process. Redcourt DS0000020081.V324410.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals living in the home have varied routines that give them opportunities to develop independent living skills and wider social contacts. Contact with family and friends is promoted and supported. EVIDENCE: Discussion and observation confirmed that the daily routines of the home are flexible and promote individual independence and choice, in accordance with their support needs. In recent years the home’s staff have become more outward looking with the people who live there and contact with family and friends and outside facilities are encouraged; care records confirm this. This helps them broaden their lives, building up self-confidence and enriching their experience of life. The home has continued to ensure that service users have the knowledge and skills to support them in being more independent, and there are options provided by the University of Derby within the day centre. All residents have 2 full days within this environment and links are being made with the local Social Services unit for one resident also. Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 13 Residents talked about being actively involved in cooking, domestic activities including laundry and in the maintenance of the grounds, although staff reported that success in this area varied according to capability. One resident also has voluntary work within the local community. Staff actively support service users to go to pubs and shops in the local community and during the inspection a small group went to the local supermarket to get money from their bank accounts. Residents spoken to also described regularly doing such activities as ten-pin bowling, cinema and hill walking. Another talked about his holiday in Spain this year, whilst he waited for his mother to pick him up for a Christmas lunch. Copies of the recent menus were looked at before the inspection and lunch in the men’s unit was observed being served up. All residents are invited to make a choice over meals and some were able to describe their favourite preferences from what is a well-balanced cosmopolitan menu. The residents’ meeting is regularly given over to a discussion with the cook to plan the future menu and staff assist using pictures and other visual means of communication, so that people can express themselves properly. Some special dietary arrangements are monitored by staff such as both weight reducing and weight gaining. Discos and parties are regularly enjoyed in the home when all of the residents come together for a special meal; this includes Christmas and Halloween. It was mentioned by staff that in the past there have been General Meetings and an Open Day to which families were invited – milestones in the changing philosophy from a closed institution to a modern open and developing service. Redcourt DS0000020081.V324410.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal and health needs of residents are dealt with in a satisfactory way, and support from outside professionals is good. This has resulted in them gaining access to services like everybody else. Attention to minor issues in medicines administration will make this system completely safe. EVIDENCE: Residents continue to receive specialist services from the local Learning Disability Service including the occupational therapist, speech therapist, physiotherapist and social worker. They receive good support from the primary care team and one GP is a trustee of the home. Service users have received flu jabs and the home is involved in the health action plan for Glossop and Tameside. One important aspect of the current review of the service provided by the home has been the recognition that the resident group is ageing and a small number have started to show signs of early dementia that is also associated with the onset of epilepsy. Staff are due to receive training in theses subjects to help them provide a good quality service and to make sure that care is appropriate. There has been a further death at the home this year and another resident has recently gone through a very rapid decline in her health, Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 15 prompting regular contact with local services over managing her care appropriately; the District Nurse was present during the inspection. Dependency levels amongst the home’s residents vary, although it was clear from discussions with staff during visits to both of the living units that the men’s group is more independent. Levels of support required by individuals is identified in care plans and staff are attentive to individual needs rather that responding in a routine way for all. There are no residents with substantial physical disabilities and the majority are in robust good health. All those that have prescribed medication require staff’s help with management and administration. General aspects of this were satisfactory although there were a small number of handwritten inclusions on the medicines record that had not been signed and dated, and temperatures of the medicines refrigerator were not being maintained. This could lead to errors on medicines administration and unsafe practice. Redcourt DS0000020081.V324410.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by having their rights to complain upheld and through staff understanding their responsibilities to report concerns. EVIDENCE: The home has an established complaints procedure, which is available to residents and their families, and advocates are available if there is a need for individuals to have independent advice. One complaint has been documented in the records although, as this was an incident between two residents that resulted in hospital treatment, it was also referred through the statutory procedures for the Protection of Vulnerable Adults. The matter was discussed with the relevant personnel from Social Services and the Police and this demonstrated a good level of understanding by the home’s management. New staff receive instruction within induction training, and others have received updates so that all are clear about their responsibilities to be alert and report where necessary. Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have benefited from a much-improved living environment that is becoming more homely and less institutionalised and which includes bedrooms that are equipped to meet their personal needs. EVIDENCE: The home has continued to undergo changes in its style and appearance in order to make it more homely and less institutional. Bedrooms are all single and replacement furniture has continued to be provided in order to make them look more modern and age-appropriate. All those visited showed signs of personalisation by the resident and they are increasingly using the bedrooms as ‘bedsitting rooms’, indicating an awareness of their independence and selfdetermination. The increasing availability of computers in the living areas rather than classroom is another example of this process-taking place for some residents. The overall programme of maintenance, redecoration and refurbishment is ongoing and the home was in a good standard of cleanliness on the day of the inspection. Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 18 The two units operate more or less independently with their own laundries for personal clothing and resident training, and kitchens for preparation of breakfasts, snacks and hot drinks. There is however only so far that the home can go to meet the requirements of the law for 10-bedded units and, as noted above, discussions are continuing to plan a different service; this could result in a considerably changed physical environment that which will meet modern requirements. The CSCI is being routinely updated and included in this process. Redcourt DS0000020081.V324410.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All staff employed by the agency receive careful recruitment checks and good systems of training and support, so that the interests of residents are protected. Their overall welfare is undermined by a shortfall in achieving the minimum standard of NVQ qualification. EVIDENCE: The staff rota indicates a good level of cover and staff described a relaxed working environment that allowed them to work with residents as individuals as well as in small groups. The two units are staffed more or less independently although gaps in the rota are covered by who is available and willing to pick up extra shifts. Records indicated a good system of staff recruitment in operation of the home; this ensures that the right people are chosen to work at the home. All new staff now undertake induction and foundation training to Learning Disability Award Framework (LDAF) standards and this national standard underpins all training given. A new training coordinator has recently been appointed who will have responsibility for making sure the right training is provided to staff when they need it. Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 20 Staff confirmed that they have benefited from a good standard of training and development time with each Friday identified as a training day for one shift, so that everybody gets an opportunity in one week in three. The manager indicated that the home benefited from inputs from health professionals to ensure that staff had the knowledge to respond to a range of needs. In response to the changed needs of one the residents, noted above, there will be training on the management of dementia and epilepsy in the early part of next year. Staff also receive training from the home’s pharmacist before they are allowed to be responsible for the administration of medicines, ensuring safe practice. Training records indicated that a number of staff have recently started NVQ courses and the required target of the NMS should be met by the middle of next year. Staff said that they receive good levels of support in carrying out their work and this has improved with the appointment of two assistant managers who are responsible for the day-to-day running of the living units. Between them they are responsible for providing staff with informal support as well as formal one-to-one supervision. This system has recently started up and the targets for this should be achieved in the first part of next year so that the work practice of all staff will be monitored and consistency and safety applied. Redcourt DS0000020081.V324410.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in the best interests of the residents and overall good systems and administration and staff training support standards of safety and quality. EVIDENCE: The home benefits from a registered manager who has had many years of experience of working in the home and knows the residents very well. She has been instrumental in introducing the changes that have occurred at the home in recent years and continues to be strongly committed to making further progress. She is due to complete the Registered Manager’s Award in the early part of 2007. She is supported by an active Director of the home and a Board of Trustees who are committed to change. The home has carried out a range of quality assurance activities during the past year that indicates a reflective approach to running the home in the Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 22 interests of the residents. There is now a residents’ meeting every two months and the manager indicated that the residents are learning to speak out and gain more control over their lives. A quality assurance questionnaire has been sent out to all residents and this is planned for a follow up that will seek out views on meals and menus. Appropriate arrangements were in place for the health and safety of residents including the training of staff in basic first aid, moving and handling, food hygiene, fire safety and control of infections. Information received before and records examined during the inspection indicated that all routine safety checks were in place and that overall standards of safety were being maintained. Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 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 3 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 2 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 24 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 YA9 Regulation 13(4) Requirement The risk assessments of residents must be updated to reflect changes in their lives for example in behavioural and health care needs, and should be subject to review at regular intervals, at least annually. Handwritten instructions on the MAR sheets must be clearly recorded, dated and countersigned by two people. The target of 50 of staff achieving the minimum of NVQ level 2 must be achieved by the due date. Timescale for action 31/03/07 2. YA20 13(2) 31/03/07 3. YA32 18(1) 30/06/07 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. Refer to Standard YA6 Good Practice Recommendations Care plan documentation should be written up using the Personal Planning Book format for all residents. All care documents should be signed and dated by the person responsible for completing them. DS0000020081.V324410.R01.S.doc Version 5.2 Page 25 Redcourt 2. 3. 4. YA20 YA36 YA37 Daily records of the temperature of the medicines refrigerator should be maintained. Staff should receive formal 1-to-1 supervision at least 6 times a year. The manager should achieve qualification in the Registered Manager’s Award by the agreed date Redcourt DS0000020081.V324410.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Redcourt DS0000020081.V324410.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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