Inspection on 19/12/05 for Saxby

This inspection was carried out on 19th December 2005.

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

Other inspections for this house

Saxby 22/08/07

Saxby 25/07/06

Saxby 27/06/05

Saxby 11/01/05

Saxby 20/07/04

Saxby 14/01/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Saxby Upton Road Upton Aylesbury Bucks HP17 8UA Lead Inspector Mrs Maureen Richards Unannounced Inspection 19th December 2005 09.45 Saxby DS0000029711.V270334.R01.S.doc Version 5.0 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 Saxby DS0000029711.V270334.R01.S.doc Version 5.0 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. Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Saxby Address Upton Road Upton Aylesbury Bucks HP17 8UA 01296 749969 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) Linda.Hodges@parkside.org.uk Turnstone Support Limited Mrs Linda Hodges Care Home 4 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: Saxby is a small care home that is registered to provide care and accomodation to four service users with a learning and physical disability. The home is managed by Turnstone Support. Saxby is situated in Upton, which is a small village on the outskirts of Stone, but it is accessible to Aylesbury and Thame town centre and amenities. Access to amenities is via the homes own transport. The home is on a bus route to local villages and towns. Saxby is a single storey building, which has been refurbished and adapted to meet the needs of the service user group. All of the bedrooms are single. There is a car park at the front of the property and an enclosed rear garden. Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Saxby took place over six and a half hours on the 19th December 2005. The inspection consisted of discussions with the manager and senior, an informal introduction to service users and examining records. The outstanding key standards were assessed and the progress with requirements from the last inspection were reviewed. The requirements made at the last inspection related to the development of policies which has not been complied with. The relevant polices seen at the home remain overdue for review and update. No comment cards were received to date in respect of this service. What the service does well: What has improved since the last inspection? What they could do better: Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 6 The manager must ensure that the completed assessment documentation for prospective service users is maintained at the home. A service user file must be developed for prospective service users with the key information and known risks at the point they commence periods of leave to the home. Service user plans must be kept updated and reviewed and show evidence of discussion and involvement of service users. The new service user format should be put in place for all service users to ensure consistency and the previous high quality in the standards of service user plans. The organisation must be more proactive in responding to requirements relating to updating and review of relevant policies. Staff files must be further developed to include all of the required information as outlined within schedule 2. A fire drill must take place and a system be put in place to ensure that fire drills take place as outlined within procedures. 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. Saxby DS0000029711.V270334.R01.S.doc Version 5.0 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 Saxby DS0000029711.V270334.R01.S.doc Version 5.0 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 Completed assessment documentation for prospective service users is not maintained at the home which may indicate that the home does not carry out thorough assessments of prospective service users to ensure they can meet their needs and to ensure that the individual is compatible with other service users living at the home. EVIDENCE: The home has a vacancy and a prospective service user has been assessed with a view to moving into the home. At this inspection this individual had commenced periods of leave to the home. The manager confirmed that she has been involved in the assessment of this individual with the Regional Manager and meetings have taken place with the relevant professionals to ensure that there is a smooth transition from this individual’s current placement to the home. The home has a copy of a care manager’s assessment of this individual but there is not completed assessment documentation to indicate that the home carried out their own assessment or minutes from meetings to indicate planning meetings had taken place. The manager confirmed that the assessment documentation is at head office waiting to be typed up. A copy of the handwritten assessment must be maintained at the home until such time as the typed copy is available. Minutes of planning minutes and pre discharge minutes should be taken to ensure that all areas discussed are recorded and agreed. Saxby DS0000029711.V270334.R01.S.doc Version 5.0 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 Service user plans are specific and detailed in plan of care, however not all service user plans are reviewed and indicate service user involvement which could potentially put service users at risk. Service users are supported to make decisions about their lives, which enables them to be involved in aspects of their care and life at the home. Specific and generic risk assessments are in place, which promotes the health, safety and welfare of service users. EVIDENCE: Three service user plans were viewed at this inspection. Each service user has two files, one daily file and one file which includes all information pertinent to each individual. Both files include a photograph of individuals. The files seen include a personal details information sheet, however the documentation on file does not make reference to what the service user likes to be known as. The standard of service user files were found to be varied. All of the service user plans included detailed information on the level of support required by individuals to meet all aspects of their care needs. Two of the service user plans indicated that they had been discussed with the service user. Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 10 Some plans included separate support plans to support the individual to develop their skills and independence, none of these support plans were signed and did not include date of implementation or date of review. Two of the service user plans were overdue for review. The manager confirmed that service user plans were being developed into essential lifestyle plans and this had resulted in current service user plans not being reviewed. One of the service users had an essential lifestyle plan on file. This was found to be detailed and included staff initials to indicate that they had read the plan to enable them to support the service user with his care needs. However this essential lifestyle plan was not signed by the staff member or the manager and showed no indication of being discussed and agreed with the service user. There is a noticeable deterioration in the standard of service users plans from the previous inspections possibly as a result of the introduction of a new format. It is hoped this will be addressed with the introduction of essential lifestyle plans in all of the service user plans. The prospective service user was scheduled to spend his first overnight leave at the home. There was no service user plan in place for this individual. The manager confirmed she was in the process of developing a service user plan with him. In the meantime key information including known risks must be made available to staff. Staff continue to work with service users in supporting them to make decisions and choices. Objects of reference are available to enable one service user to make choices. The other two service users are able to indicate their choices and decisions by verbal and non-verbal communication. The home has an advocate who attends reviews and specifically visits one service user who has minimal family contact. Service user plans makes reference to the level of support required by individuals to manage their finances and Turnstone act as an appointee for some service users. Each service user plan included a series of individual and generic risk assessments. The manager confirmed that the risk assessments documentation is in the process of changing. One of the service users risk assessments was overdue for review. Service user plans included a separate moving and handling assessment, which were all up to date and showed evidence of being reviewed. The home has a missing persons procedure, which was reviewed in 2004 and is overdue for review since November 2005. This procedure includes notification of a missing person to the Commission. Standard 10 was not assessed. A requirement was made at previous inspections for the confidentiality policy to be reviewed and updated. As part ot that review the policy needed to be updated to make it clear to staff that information given to them in confidence must be shared with the manager and relevant others. This has not been complied with. Saxby DS0000029711.V270334.R01.S.doc Version 5.0 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 A range of activities is made available to service users which promotes personal development. Family involvement and friendships are supported and encouraged to enable service users to develop and maintain family links and appropriate relationships. Individual routines are outlined in service user plans which ensures service users rights are respected and their privacy and involvement in decisionmaking is promoted. EVIDENCE: None of the current service user group are involved in job placements, further education or training. Some service users have specific activities with the Connect team who are based at Turnstone head office and see service users in the home, escort them for activities out of the home or service users attend a session at the head office. Staff support service users with benefit queries as required. Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 12 Staff have worked hard in supporting service users to become part of and participate in the local community. Service users are encouraged to try new activities and staff gauge from their reactions and responses as to whether they liked an activity or not. Service user plans include a record of activities that have taken place each month. Information on local activities are displayed on the notice board and discussed with service users. The home has it’s own transport. Service users are on the electoral roll. Staff time with service users is flexible including evening and weekends. On the afternoon of the inspection three service users and two staff went to Milton Keynes to see the Christmas display, shopping and a meal. The home has no service user from an ethnic minority background. Some service users have family involvement. One service user’s relative is specifically involved in some one to one activities with the service user. Visiting is flexible. Service users can see visitors in their bedrooms or in communal areas of the home. Service users have developed friendships with service users from other homes and they tend to visit each other. Service users would be supported if they wanted to develop a personal relationship. Service user plans makes reference to supporting individuals to develop their independence and this continues to be promoted and developed on. Staff knock on bedrooms doors prior to entering and do not enter if the service user is not there, this was evident during the inspection. Service users have a key to the front door and bedroom and they are encouraged to use their key when entering the home. Service users are supported to open the door to visitors. Service user plans make reference to the level of support required by individuals to manage their post. Staff confirmed that service users are called by their preferred name but service user plans do not make reference to this. Staff talk to and involve service users in all conversations. Service users can choose not to take part in an activity and the daily entries in service users plans support this. Service users have unrestricted access to all areas of the home. Service users are being supported and encouraged to become involved in housekeeping tasks. Saxby DS0000029711.V270334.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Service user are supported to meet their personal care needs whilst promoting their independence and privacy. EVIDENCE: Service user plans include moving and handling assessments which outline how service users are to be moved and guided. Service user plans make reference to the level of support required with personal care and support and in choosing clothes. Times for getting up and going to bed are flexible and are dependant of the service users responses and reactions. Service users have specific aids and equipment provided to promote their independence. The home has access to specialist services through the GP and the learning disability team based at Manor House. Service users have a designated keyworker. Service user plans outlines service users preferred routines, likes and dislikes. Standard 20 was not assessed. A requirement was made at previous inspections for the medication policy to be reviewed and updated. This has not been complied with. Standard 21 was not assessed. A requirement was made at previous inspections for the policy on managing death to be reviewed and updated to include notification of a death of a service user to the Commission. The policy Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 14 has been updated to include notification to the Commission but the date of the policy remains unchanged as July 2001. Saxby DS0000029711.V270334.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standard 23 was not assessed. A requirement was made at previous Inspections that the whistle blowing policy and adult protection policy must be developed in line with interagency procedures. The whistle blowing policy has not been reviewed. The adult protection policy indicates initial action to be taken in the event of suspected abuse. This procedure is very wordy and does not make it clear that in residential care the organisation has a responsibility to report any allegation of abuse with or without the service users consent. It is not clear if this policy has been reviewed and updated, as the date on the policy is 2000. A requirement was made at previous inspections that the organisation must update the management of violence policy to include that any incident is reported to the Commission. This has not been complied with. Saxby DS0000029711.V270334.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The key standards were inspected at the previous unannounced inspection. The home is clean, bright and welcoming. At the time of the inspection it was nicely decorated with Christmas decorations. Two of the service users bedrooms have been decorated and new bedding and furnishings have been purchased with the service users involvement. Under standard 30 a requirement was made at previous inspections for the infection control policy to be reviewed and updated. This has not been complied with. Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 17 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 & 36 Staff have the necessary skills and training to meet service users needs. The home has safe recruitment practices in place to safeguard service users however, further records are required to ensure staff files are developed in line with the regulations. The majority of staff have up to date mandatory training and systems are in place to ensure that this is maintained which ensures that service users needs are met by appropriately trained staff. Staff are supervised and supported in their roles, which ensures that they carry out their role effectively to benefit service users. EVIDENCE: Staff are accessible to, approachable by and comfortable with service users. They have developed a good understanding of service users needs and in particular their communication needs. The manager confirmed that staff are reliable, honest, interested, motivated and committed. This is evident from the continuous development of this service, in particular supporting service users to develop new skills and promoting activities. Staff have attended specialist training in dementia, epilepsy, positive approaches to working with clients who may challenge and communication training. The home has developed professional relationships with GPs and other professionals involved with the home. One staff member has an NVQ 2, two staff are currently enrolled on an Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 18 NVQ 2 and one staff member is due to commence NVQ 2 training in January 2006. The manager and senior have obtained an NVQ 4. Three staff files were viewed at this inspection. The staff files seen contained confirmation of CRB clearance, two references, copy of application form, copy of terms and conditions, copies of passport and driving licence. One of the staff files contained confirmation of medical clearance and only one of the files contained a copy of a recent photograph of the staff member. Staff files must be further developed. New staff, agency and sessional staff are inducted into the home. Each staff member has an individual record of training undertaken and the records indicate that the majority of staff have up to date mandatory training. The manager and senior are aware that some mandatory training is now due for some staff and their names have been put forward to head office for the next training event. Staff files indicate that staff are offered regular supervision and they are supported in their roles. The manager and the senior carry out the supervision and they have both attended supervision training to support them in this role. Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 19 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 & 42 The home is well managed which benefits service users. The home has systems in place to ensure the health and safety of service users. Regular fire drills must be carried out to support this. EVIDENCE: The registered manager has worked hard in developing this home to benefit service users. She has developed a cohesive team who appear to work well together in promoting the aims and objectives of the home. She has obtained her NVQ 4 in management and is currently undertaking NVQ 4 in care. The manager has systems in place to ensure that staff read and understand polices and procedures. Certificates and licences are displayed and the manager is proactive in meeting requirements relating to the home. Requirements are outstanding from previous inspections, which are the organisation’s responsibility. Standard 39 was not assessed at this inspection. A requirement was made at the previous announced inspection that the organisation must send a copy of Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 20 the results of the audit to the Commission by the 31st December 2005. The manager has obtained feedback on the home from service users and has developed an action plan to address findings. She intends to carry out observation of staff practice as part of this audit. The manager is not sure how feedback is sought from relatives and relevant professionals. The organisation is reminded to send a copy of the full results of the audit to the Commission as required at the last inspection. Staff have the required mandatory training and systems are in place to ensure that this is maintained and kept up to date. The home has an emergency procedure information sheet, which outlines the action to be taken in the event of a gas leak, flooding, power and gas supply failure. The home has a gas safety record in place which indicates that a service was carried out in August 2005. The home has a work sheet to confirm that the portable appliance testing has been carried out but there is not service record to confirm this. The labels on the equipment in the office confirm that the electrical equipment was tested in October 2005. The hoists at the home are overdue for a service. The manager is aware of this and had written to the company contracted to do this work to arrange for this service to take place as soon as possible. The home has a series of generic risk assessments, which were reviewed in December 2005. The home has COSHH data sheets in place. The home has records of accidents and incidents. Records of accidents and incidents pertaining to service users are kept in the service user file. The home has written guidelines on the fire procedure. The home has an up to date fire risk assessment. The home has fire records in place, which indicate that an emergency lighting, call alarm test and fire bell tests are carried out and checked weekly. The records indicate that the last fire drill was in July 2005 and this is now overdue to take place. The home has records in place to confirm that the fire equipment has been serviced. The home has dorguards in situ and a check of the dorguards are carried out weekly. Radiators at the home are covered and the water is thermostatically controlled. The home had an environmental health visit in August 2005. All areas were found to be satisfactory. Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Saxby Score 3 x x x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 2 x DS0000029711.V270334.R01.S.doc Version 5.0 Page 22 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 YA2 Regulation 14 Requirement The manager must ensure that assessment documentation for prospective service users is maintained at the home and key information and known risks are made available to staff prior to the service user spending periods of leave at the home. The manager must ensure that all of the service users plans are updated with the essential lifestyle plans, kept under review, signed and indicate discussion with service users. The whistle blowing policy and adult protection must be developed in lien with interagency procedures. (Pevious timescale of the 31/03/05 and 31/08/05 not met) The organisation must update the management of violence policy to include that any violent incident is reported to the Commission. (Previous timescale of the 31/03/05 and 31/08/05 not met). Staff files must be further developed to ensure they contain DS0000029711.V270334.R01.S.doc Timescale for action 31/12/05 2 YA6 15 31/01/06 3 YA23 13 31/03/06 4 YA23 13 31/03/06 5 YA34 19 31/01/06 Saxby Version 5.0 Page 23 6 YA40 Appendix 2 7 YA42 23 the required information as outlined in schedule 2. The confidentiality policy, 31/03/06 medication policy and the policy on infection control must be reviewed and updated. (Previous timescale of the 30/04/05 and 31/08/05 not met) A fire drill must be carried out 31/12/05 and a system put in place to ensure regular drills take place in line with the organisations procedures. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Saxby DS0000029711.V270334.R01.S.doc Version 5.0 Page 25 - 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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