Inspection on 09/05/06 for Rutland Villa

This inspection was carried out on 9th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rutland Villa 11/05/07

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Rutland Villa Rutland Villa 62 Chesshire Avenue Stourport on Severn Worcs DY13 0EA Lead Inspector M Nethaway Unannounced Inspection 9 & 11th May 2006 10:30 th Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 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 Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 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. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Rutland Villa Address Rutland Villa 62 Chesshire Avenue Stourport on Severn Worcs DY13 0EA 020 8863 0335 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) Minster Pathways Limited Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one young person (aged 17). Date of last inspection Not applicable. Brief Description of the Service: Rutland Villa opened in November 2005 and can accommodate three people, one young person under the age of 18. The home is in a residential setting, located two miles on the outskirts of Stourport. Public transport links are available. The home is domestic in scale and provides a small group living environment. At the point of this inspection visit, there was one placement vacancy. The registered manager resigned in March 2006. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This new home was opened in November 2006, unfortunately the registered manager left in March 2006. This inspection was a key inspection visit, unannounced and taking place over two days covering a Tuesday and Thursday, carried out by one inspector. The visit covered the mid morning and early evening routines. All twenty-one national minimum standards were assessed. The inspector concentrated on examining the care files, the necessary paperwork and discussions with staff. Time was spent with service users during the guided tour and while waiting for the evening meal. Discussions took place with the deputies. Some key policies and procedures were also examined. What the service does well: What has improved since the last inspection? What they could do better: • • • • • • • The quality of the care planning records is only adequate and requires further improvements. The Person Centred Planning approach could be a more comprehensive tool. The home should liaise with advocacy services. This will enable the home to have access to an independent organisation. Risk assessments need to be more rigorous and ensure a thorough assessment of risk. Staff training should address the cultural and religious needs of service users. The provider needs to ensure that staff training is given a higher priority and care staff need to be registered with the Learning Disability Award Framework. The provider should be more proactive with implementing a quality assurance system. This will reflect a cycle of ongoing evaluation. This will ensure that service user’s outcomes are measurable. Overall, the quality of record keeping needs to represent the level of input and care practice provided to the service users. Staff should receive training in this area. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 6 • • Some key methods need to be implemented in relation to complaints and allegations. The provider needs to ensure stability with the arrangements for the management of the home. The homes potential to deliver the best possible outcomes for service users should not be compromised. 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. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 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 Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Good arrangements are in place to assess the needs of each individual’s. Admission records need to reflect how families are engaged in the process. EVIDENCE: The home had available a policy that outlines how the admission of new service users will be achieved. The provider is reliant upon the initial assessment being undertaken by the social worker or the placing authority. There was evidence of this available on one file examined and not in the other one. The provider has developed a comprehensive assessment for new admissions. There needs to be evidence of how families contribute to this process and how their interests, are taken into account. There was a tool available to assess any potential areas of need and to identify areas of strength for service users. The information gathered was to inform the care plan. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 The quality of care related to care planning was assessed as adequate. The tools used to provide information for care plans needs modifying. The process available for consultation is adequate and improvement with accessing advocacy services needs to be considered. Adequate attention is given to health and safety matters and the risk assessment process needs to capture risks to the individual as well as in a group living environment. EVIDENCE: The home has a system in place to address the assessed care needs of individuals. The care plan initially adopted by the home was considered limiting. The new care plan being implemented does not meet with the expectation of providing a coherent and comprehensive plan. It does not aid or assist care staff in understanding or providing relevant information relating to the aims and objectives of the care plan. There was a confused approach with the new shortened version and this was discussed with one of the deputy’s. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 10 The care plan does address how service users behaviour will be managed and supported. But evidence was found in the files, of records not being completed in relation to daily monitoring sheets, self-harm, or challenging behaviour records. The care plans are not adapted to widget or signs and symbols format. The provider should explore Valuing People, Person Centred Planning and consider implementing this model of care planning. As the service is small it would lend itself readily to this, good practice model. Service users are allocated a keyworker and co-worker and staff described a clear understanding of this role and keyworking tasks. There was good evidence of collaborative work between staff and families in relation to developing and retaining interests and the pursuit of hobbies. One service user is a keen fan football and staff showed insight and knowledge in extending this interest. Staff are paying good attention to the religious and cultural needs of service users. There was evidence of input from families and staff obtaining information from the local library and using the search engines on internet websites for one particular service user. Staff encourage service users to participate in decision making and making choices. Service user’s who are assessed as vulnerable individuals and are offered close supervision and direct staffing input. There are no structures in place on how consultation is facilitated or monitored. A system needs to be developed to demonstrate when choices have been made to maintain duty of care or on the grounds of protection and vulnerability. No links have been established with local advocacy groups and no literature was available in the home to advertise this resource. The home had available a policy related to health and safety matters. Risk assessments are carried out for service users and were found to be within the review timeframe. When examined there was a striking resemblance between the content and the assessment of risk in all of the case files. Service user’s risk assessments should be tailored to each individual’s needs. There was one example of monitoring a service user while bathing, but the protocol did not explain how often this was required. The deputies should audit the content and review the assessment of risks to ensure a proper balance is struck. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, & 17 The arrangements for meeting service user’s recreational needs and accessing the local community are good. Service users are confident about maintaining contact with family members. The home promotes daily involvement of individuals with routines on a day-today basis. The menu planning is adequate and further input from a dietician should be considered. Formalised training to meet the cultural and religious needs of service users, to fully equip staff knowledge and understanding is recommended. EVIDENCE: The home has the capacity to support service users in an education setting. The case notes indicated ongoing liaison with the school and parental involvement where possible. Staff are involved with providing transport to and from school. Staff enable the practical arrangements of school uniforms, home work and lunch not to hinder attendance school. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 12 The home is developing extra curriculum activities within the local community. The deputies have liaised with the leisure centre to explore the options of using the swimming pool. Other local activities include using the local parks, forest walks and shopping facilities. One service user has made significant progress with accessing the local shop and it is a regular part of his routine. It is recommended that the organised activities should form part of a planner or schedule for the week. The aim and objectives of the activities can be incorporated in this plan. There was good evidence of involvement with families and this was actively encouraged. Case files showed that birthdays were marked and celebrated. The home is domestic in scale and has the capacity to accommodate visitors without too much intrusion for existing members of the group. The case files need to demonstrate how service user’s right to vote has been addressed. During the visit, service user’s involvement with menu planning was witnessed. Staff enable individuals to make concrete choices through the use of pictures and digital photographs. In contrast the record keeping related to daily events is very brief and does not provide any evidence of how choice making is being facilitated by staff. The menu planning addresses one service user’s specific cultural food needs. The home is working in partnership with the family. It is recommended that staff should receive formal training and are provided with the necessary information to equip them to be able to meet cultural, religious beliefs and dietary needs. The dietician should also be contacted in relation to obtaining expert advice in terms of reviewing the nutritional value of menu planning. Records relating to risk factors associated with weight-monitoring including low and overweight needs further consideration. The deputies needs to declare how service user’s mail is being opened and clearly state this in the case file and records to support this decision. The staffing ratio is good and the availability of staff to provide one to one support is addressed. How staff are managing this time is less clear. When the inspector arrived at the home, one care staff member was reading a newspaper. The service user was not seen to be participating in this activity. At a wider level, staff discussions identified service users were spoken about positively and staff consider the rapport developed as upbeat. The daily records reflected how service user’s skills were being supported, for example bed changing. Overall, these records are very brief and possibly do not reflect all the good work that is taking place with individuals. The service user guide needs to discuss service user’s responsibility for house keeping tasks. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 13 There was lots of evidence of individuals choosing to spend time apart from each other and only convening for meal times. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 The home is able to provide good support and staffing input related to the assessed needs of service users. The provision for health care and ongoing assessment is good. Record keeping is adequate and further improvement to reflect the daily care practices needs to be developed. The pharmacist inspector will assess the safe handling and storage of medication. EVIDENCE: The staffing ratio permits service users to have one to one time with care staff. Staff described how the service is small and this provides opportunities for good staff input and low staff sickness is evident. The working environment was described as relaxed and responsive to the needs of service users. Records connected to individuals preferred routines, assessed needs, and personality should be reflected in the home’s records. At a care practice level this is occurring. Staff were able to describe at a broader and deeper level what actually works in practice at the home. But it was difficult to extrapolate from the records when examined. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 15 The make up of the staff group needs reflect to the ethnic diversity of the resident group and this is particularly important in relation to language and culture relativism. The health needs of service users are assessed and good attention is given with input from primary health care professionals. Records examined demonstrated that the home would act promptly if there were any concerns about underlying health needs. To support the good practice it is recommended to implementing Worcestershire Health Action Plans. This will assist with consolidating all the information in one place. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Good arrangements are in place to protect service user’s needs and are underpinned by appropriate policies. EVIDENCE: The home has available a complaints system that is accessible for service users. Information is available in Widget format. It is not clear from the documents examined if there is any involvement of a speech therapist in assessing the appropriateness of these documents. The provider should consider consultation with the local Total Communication Team. The provider needs to consider how service users are to be helped to access advocacy services. A formal record relating to any issues raised or complaint needs to be implemented including details of the investigation, action taken and outcome, and the record should be checked quarterly. Likewise a formal record needs to be introduced for recording all allegations and incidents of abuse and action taken. There were no live issues relating to the protection of vulnerable adults and a policy and procedure was available at the home. A whistle blowing policy needs to be developed. Records relating to financial recording keeping were examined and were assessed as satisfactory. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The home is in a good standard of repair and is kept clean. Suitable arrangements are in place to meet with health and safety matters. The provider should consider purchasing tougher furniture for one bedroom in the home. EVIDENCE: The home is located about two miles outside the town in a semi rural location. There is access to public transportation although service users mainly use the people carrier and a minibus. The home was maintained to an acceptable level of cleanliness and during the visit the carpets were being replaced with wood laminate. The home has a designated maintenance person who is regularly servicing and refurbishing the interior and exterior fabric of the building. This ensures the home will remain in a good state of repair. It is recommended that consideration be given to one service user’s bedroom, with making available a more suitable table and chair. There was three items of outdoor plastic furniture being used and understandably this was in response to the potential for furniture being thrown or broken. A more Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 18 appropriate arrangement should be followed as toughened furniture can be purchased to meet these needs. The home has available a clear policy outlining how health and safety matters are to be addressed. A policy for infection control is available. Laundry arrangements at the point of registration were assessed as being satisfactory. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 The provision for training is assessed as adequate. The provider needs to organise a clear training plan that is consistent with providing suitably qualified care staff. A couple of key areas were identified as falling short of this expectation. The selection and recruitment processes were found to be systematic and satisfactory. EVIDENCE: The recruitment and selection processes were examined. Four staff member’s files were looked at. All the necessary checks were completed and available on the files. The previous manager had set up a system that was easy to audit. The only weak area is the reference requests proforma. References must include telephone conservations with the referee. A record of this should be kept and must be signed and dated. All staff spoken to described a rigorous selection process including the completion of an application form, attending an interview and a minimum of a three-months probationary period. There is a planned approach to inducting staff and two staff were able to provide evidence of the material covered as part of their induction process. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 20 Three staff are qualified at NVQ level 3. Two further staff are undertaking training to NVQ level 2. One of the deputies of the home is currently studying for the Registered Managers Award and is expected to complete in September 2006. The provider needs to ensure that all staff have a training plan that is linked to the appraisal process that is in operation at the home. Careful attention will need to be given to providing staff with the opportunities to receive five days training and developments days (pro rata). This was discussed with the manager during the inspection feedback process. The training schedule for the home was examined and plans are underway to address core and external training programmes. One area that does need attention relates to diversity and meeting cultural needs as represented by the needs of the individuals in residence. All staff should be registered with the Learning Disability Award Framework. This is considered a key part of training for residential workers in the field of disability. It is recognised that this is a new care staff team and the constraints of operating the home since November 2005 have been considerable. As the service is small in scale this should not preclude the providers ability to organise the necessary training in a timely fashion. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, 42 The management arrangement must be focused on the stated aims and objectives of the service. The disruption of a manager leaving could undermine the homes potential to deliver the best possible outcomes for service users. This is critical as the service is new and just being established. A new manager must be appointed at the earliest opportunity. The provider needs to develop a quality assurance system that engages service users and all major stakeholders. EVIDENCE: Since the last visit, the registered manager resigned in April 2006. The deputies are responsible for the day-to-day management of the home. One of the deputy manager has a BTEC in Care, six years of significant/supervisory experience in a childcare setting. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 22 The next manager will need to make contact and undertake periodic training and development that is consistent with the expectations of the TOPSS. The provider needs to develop a comprehensive quality assurance tool to ensure consultation with major stakeholders and staff. There is a distinctive lack of structure or system in place to adequately address how the provider is self-monitoring and improving the quality of the service. This is an area that requires further consideration to ensure that it is based on a systematic cycle planning-action-review, reflecting the aims and outcomes for service users. The provider needs to identify the key policies and procedures that should be reviewed regularly. There was good evidence of health and safety matters being taken seriously and acted upon. Fire safety was clearly addressed in the policy and records reflected ongoing training. The number of fire drills exceeded the expectations of the standards. There were ample first aid boxes and staff are receiving training as part of the induction process and senior staff are attending a twoday training course in First Aid. The arrangements for domestic installations were checked and were found to be with the timeframe for maintenance. There was a good range of risk assessments and accident records are being kept. The health and safety poster displayed in the office needs amending in light of the management changes. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 2 30 x STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 x 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 x x 2 x 2 x x 2 x Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA22 Regulation 22 Requirement Timescale for action 30/09/06 2 YA23 12 3 YA24 23 4 YA39 24 The provider must maintain a record related complaints system that clearly details the investigation, action taken and records the outcomes. This record will need to be checked quarterly. • The provider must 30/09/06 maintain a record of all allegations and incidents of abuse and action taken. • The provider must develop a Whistle blowing Policy. The provider must provide more 30/09/06 suitable furniture that is in keeping with a domestic environment. This furniture must be tough enough to withstand being thrown. The quality assurance system 30/09/06 must be developed in line with regulation 24 and the elements outlined in standard 39. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 25 5 YA32 18 6 YA37 9 The provider must ensure that 30/09/06 all staff have a training plan that is linked to the appraisal process. Staff must be given the opportunities to receive five days training and developments days (pro rato). • To meet the diversity and cultural needs as represented by the needs of the individuals in residence. Staff must receive appropriate levels of training. • All staff must be registered with the Learning Disability Award Framework. The provider must ensure that 30/07/06 the appointed manager makes an application to the Commission. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA2 YA6 Good Practice Recommendations The provider should demonstrate how parents contribute to the process of the assessment and how their interests are taken into account. The registered person should ensure the placement plan, • sets out assessed needs, • sets out the objectives of the placement, • and how these are to be met by the registered provider on a day-to-day basis, • the contribution to be made by the staff of the home, and how the effectiveness of the placement is to be assessed. The behaviour management tool, located in the case file, should reflect the level of monitoring conducted by staff as outlined in the document for example, daily monitoring, DS0000064213.V292990.R01.S.doc Version 5.1 Page 26 3 YA6 Rutland Villa 4 5 6 YA6 YA23 YA7 7 8 YA7 YA9 9 YA12 10 YA16 11 12 13 14 15 16 17 18 YA16 YA17 YA17 YA18 YA19 YA19 YA22 YA42 self–harm or challenging behaviour. The provider should explore the option of implementing Person Centred Planning in relation to Care Planning. The new manager should attend Child Protection training in Safeguarding Children ACPC Level 2. The provider should consider structures that demonstrate how service users are being consulted. A system should be available to determine when choices have been made to maintain duty of care or on the grounds of vulnerability. Links should be established with local advocacy groups. Risk assessments should assess the risks at an individual level. The use of generic risk assessments should be clearer. The manager should audit the content of risk assessments to determine the quality of the guidance and ensure the protective strategies are validated and effective. Organised activities, as part of the day care routines, should be recorded in a planner or schedule for the week. The aims and objectivities of the activities can be incorporated in the plan. • The arrangements to deal with service user’s right to vote should be addressed. • The arrangements for receiving and opening service user’s mail needs to be a structured process. The service user’s guide should specify the arrangements for household tasks. Records relating to risk factors associated with weight monitoring, including low weight and overweight should be considered. Menu planning and the selection of culturally relative food to properly meet dietary requirements should have input from the dietician. The care records should reflect the input that staff are providing to service users. The mix and makeup of the staff group should reflect the ethnic and cultural needs of the service users. The implementation of the Health Action plans should be considered. The provider should consider contacting the local Total Communication Team in relation to the complaint format and the use of Widget. The health and safety poster displayed in the office should be amended in light of the management changes. Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Rutland Villa DS0000064213.V292990.R01.S.doc Version 5.1 Page 28 - 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!