Inspection on 03/03/06 for Searchlight Workshops - Francis House

This inspection was carried out on 3rd March 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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Searchlight Workshops - Francis... 08/02/07

Searchlight Workshops - Francis... 21/06/05

Searchlight Workshops - Francis... 28/01/05

Searchlight Workshops - Francis... 25/11/04

Searchlight Workshops - Francis... 17/06/04

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

CARE HOME ADULTS 18-65 Searchlight Workshops - Francis House Claremont Road Mount Pleasant Newhaven East Sussex BN9 0NQ Lead Inspector Jennie Williams Unannounced Inspection 10:30 3 March 2006 rd Searchlight Workshops - Francis House DS0000059172.V249627.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 Searchlight Workshops - Francis House DS0000059172.V249627.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. Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Searchlight Workshops - Francis House Address Claremont Road Mount Pleasant Newhaven East Sussex BN9 0NQ 01273 514007 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) Searchlight Workshops Annette Shepheard Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That service users accommodated are aged eighteen (18) to sixty-five (65) on admission. That service users must have a physical disability or learning disability. The maximum number of service users to be accommodated is six (6). Date of last inspection 21st June 2005 Brief Description of the Service: Francis House is a home within the Searchlight Workshops organisation that is registered for six places for younger adults, of either gender, who have a physical disability or a learning disability. There is no nursing care offered at this establishment. The home is situated on the top of a hill on the outskirts of Newhaven. The home has access to a mini bus. There are local amenities and access to bus routes at the bottom of the hill. There are three registered establishments at this one site within the organisation of Searchlight Workshops. There is also a workshop on the site available to residents and others within the community. A variety of crafts/activities are offered at the workshop. A social club is run on site and this opens a couple of evenings a week. All rooms are for single occupancy and are located over two floors. Residents must be able to mobilise independently to access the first floor. There is suitable bathing facilities provided at the home that meet the needs of the residents. There is suitable communal space for residents. Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Francis House will be referred to as ‘residents’ This unannounced inspection took place over five hours on the 3 March 2006. The environment and some individual rooms were spot-checked. Care plans were inspected. Some policies and procedures were read. Four residents and 2 staff were spoken with throughout the inspection process. Medication procedures were assessed. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection report of 21 June 2005. There were four residents residing at the home on the day of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Risk assessments for residents who self medicate require to be regularly reviewed. Risk assessments need to be developed and implemented for areas where hot water is being delivered above the recommended 43°C, for unguarded radiators and unrestricted windows above ground floor. The Protection of Vulnerable Adults (POVA) procedures could be condensed to Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 6 provide quick and easier to read guidelines for staff. A restraints policy needs to be developed and implemented. The medication procedures need to be improved to ensure there is no double handling of medications. All medication received and administered at the home must be accounted for. As good practice, any handwritten MAR charts should be double signed by two staff who are trained in medication procedures. Residents’ inventories require to be kept up to date. 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. Searchlight Workshops - Francis House DS0000059172.V249627.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 Searchlight Workshops - Francis House DS0000059172.V249627.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): 1, 2 & 4 The home has information available to prospective residents and their representatives to make an informed decision if the home is suitable for their needs. EVIDENCE: The home has a Statement of Purpose and Service User Guide that is available upon request and provides prospective residents and their representative information on the services and care provided at the home. The registered manager undertakes all pre assessments of prospective residents. A copy of social services assessment is obtained wherever possible. There has been one new admission since the last inspection. There was evidence that a pre assessment was undertaken prior to the resident moving in. The location of the room is taken into consideration when assessing any prospective resident, as people must be able to mobilise independently between floors. Prospective residents are able to visit the home prior to moving in if they wish. The new resident confirmed that they had visited the home and viewed their room prior to moving in. Searchlight Workshops - Francis House DS0000059172.V249627.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, 8, 9 & 10 Residents’ needs are being met by the information contained in the care plans. Residents are encouraged and supported to maintain independence and make decisions about their lives. EVIDENCE: Care plans have been transferred onto a new format that provides clear information to staff on the assessed needs of the individuals. There was evidence that care plans are being regularly reviewed. Care plans are developed and reviewed with input from the resident. Residents will sign the care plans following review. Residents spoken with confirmed that staff discuss their care with them and they are familiar with their care plans. The registered manager confirmed that they propose to review care plans every three months, and every month for the older residents. All residents have their own bank accounts and provided with lockable facilities to store any money/valuables securely. Staff are assisting and education residents regarding their finances Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 10 Residents are involved in the day-to-day running of the home. Residents have an allocated day where they cook for the other residents and are also involved in the cleaning of the home. Residents spoken with confirmed that they are involved in menu planning, cooking, cleaning and some enjoy assisting with the shopping. Prospective residents are also discussed with current residents prior to admission and are generally provided with an opportunity to meet them prior to moving in. Due to the small homely environment, it is important for all residents to maintain a good relationship. There are risk assessments in place for activities of daily living that residents are involved in. There has been a new risk assessment form implemented that provides additional information for areas/activities that pose a higher risk. These forms provide staff and residents on additional action to take to minimise risk. It is recommended that risk assessments be reviewed when care plans are reviewed. All information is stored securely at the home and is used in accordance with the Data Protection Act 1998. Residents know that information given in confidence to staff will only be shared on a need to know basis. Searchlight Workshops - Francis House DS0000059172.V249627.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): 11, 12, 14, 15, 16 & 17 Residents are provided with opportunities for personal development and to be involved in the local community if they wish. Residents have opportunities to engage in appropriate leisure activities. EVIDENCE: There is a workshop and social club located on the same site as Francis House. Residents of the home are able to use these facilities if they choose. People that live outside of the home environment also use these facilities. There is a bus available at the home to transport residents. Wheelchairs can be accommodated in the bus. Management has had discussion with residents regarding the provision of activities/entertainment at the social club, as recommended from the last inspection. Some residents confirmed that this has improved. Residents are encouraged and supported to be involved in further education and employment if they choose. One resident is undertaking NVQ studies in life skills. No other resident has chosen to undertake any additional studies. No resident is interested in being involved in employment outside of the home environment. Two residents work on reception for Searchlight Workshops. Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 12 Residents are encouraged to involve themselves in activities outside of the home environment. No resident currently chooses to be involved in such activities. Staff encourage residents to maintain contact with their families and friends. One resident was supported to go home for the Christmas period. Visitors are welcomed at the home. Residents spoken with confirmed that their lifestyle and daily routines are their own choice. Staff were observed to have a good professional rapport with residents and will spend time with the residents when an individual wishes or requires additional support. Residents plan the weekly menu with the assistance from staff. Residents all have an allocated day for the preparing and cooking of meals. One resident enjoys participating in the shopping for the home. Residents spoken with confirmed that they are happy and enjoy the provision of meals at the home. Residents choose where they wish to eat their meals. Searchlight Workshops - Francis House DS0000059172.V249627.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): 19 & 20 Individual’s independence and control over their own lives is maximised with encouragement and support from staff. EVIDENCE: Residents residing at Francis House are generally self-caring and require minimal support with personal care. It was confirmed that residents require very limited manual handling assistance. Residents spoken with confirmed that they choose their own daily routines. Residents were observed to move freely within and outside of the home environment. Residents spoken to confirmed that they felt their privacy and dignity are respected. Changes in residents health are monitored and specialist advice is sought whenever required. A resident was assisted by a staff member to attend a GP appointment on the day of the inspection. Residents are encouraged and supported to attend appointments at the GP’s surgery. There was no way the Inspector could easily identify when an individual has been seen by a GP. Dates of appointments are recorded in the home’s general diary. The Inspector would have had to spend a lot of time reading through the pages to find dates. It is recommended that a checklist is implemented and Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 14 stored with the care plan of an individual to clearly identify when visits to health professionals have been undertaken. There are two residents who self medicate. These residents have been educated on the importance of storing their medication securely. When residents are allowed to self-medicate, there must be a clear detailed procedure outlined in the care plan and this procedure must be risk assessed. The risk must be reviewed at pre-determined intervals. Documented evidence must be available for this action. It is required that risk assessments for those who self medicate are kept under regular review. It is recommended as good practice that any hand written MAR charts are checked and signed by two staff who have undertaken medication training. One blister pack was noted to have an additional tablet missing. It was confirmed that a tablet was dropped when being administered and could not be located. It is required that clear records be maintained for any ‘misplaced’ medication. Clear documentation is required so that all medication received and administered at the home can be tracked and accounted for. It is required that a sample signature of all staff administering medication be obtained and stored where accessible. There were unsuitable practices regarding the administration of medication for one resident. This resulted in staff double handling the medication. The registered manager would dispense the resident’s medication into a dossette box, which had no indication who it was for or what tablets it contained. Staff would then dispense from the dossette box. Staff must administer directly from the labelled medication provided to the home from the pharmacy. Staff must be familiar with the medication they administer. The double handling of medication allows room for errors to occur. Searchlight Workshops - Francis House DS0000059172.V249627.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): 22 & 23 People involved with the home are provided with suitable information to assist them to make a complaint. EVIDENCE: There is a complaints procedure available at the home. Residents spoken to confirmed that they know who to speak to if they needed to make a complaint. There is a record kept of complaints. There have been no complaints made directly to the CSCI since the last inspection. There had been one complaint made directly to the home from one resident regarding another resident. This complaint was withdrawn. Residents were satisfied with the way the home dealt with the concerns expressed. Action taken to deal with complaints is being documented as required at the last inspection. There is a policy and procedure in place that provide staff with guidelines to follow in the event of an allegation of abuse being made. The policy and procedure for the POVA was longwinded. It is recommended that this information be condensed to provide quick, clear guidance for staff and contain the contact details of the appropriate leading authorities. It was confirmed that staff have received Adult Protection training from a company external to Searchlight Workshops. There is a whistle blowing policy at the home. There is currently no restraints policy in place. It is required that the home develops and implements a restraint policy. The home has amended the Gifts to Staff policy, as highlighted at inspection at another of the homes within the Searchlight Workshop group. Searchlight Workshops - Francis House DS0000059172.V249627.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): 24, 25, 27 & 28 Residents live in a home whose location and layout is suitable for its stated purpose. EVIDENCE: All rooms are for single occupancy and are located over two floors. Residents must be able to mobilise independently to access the first floor. Residents spoken to confirmed that they were happy with their individual room. Rooms that were spot-checked were seen to be personalised to reflect the individual’s choice and personality. The office has been moved from the ground floor to the first floor, which was previously a bedroom. The room where the office was located is being changed into a bedroom. There are now three bedrooms located on the ground floor to accommodate residents who may not be able to independently mobilise on stairs. There are cooking facilities and communal areas on each floor for the residents to use. There are suitable toilet and bathroom facilities provided at the home that meet the needs of residents. Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 17 The home was free from offensive odours on the day of the inspection. There is a rota for cleaning duties that residents are involved in. Some residents spoken with confirmed that they enjoyed being involved in the cleaning routine. Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 & 36 Residents’ needs are being met with the numbers and skill mix of staff on duty at all times. EVIDENCE: Resident spoken to were very complimentary about the staff working at the home. All residents felt that their needs were being met with the skill mix and staffing numbers at the home. Staff were observed to have a good professional rapport with residents. The home is working towards meeting the required 50 ratio of staff required to have NVQ level 2 or equivalent qualifications. One staff member has completed NVQ level 3 studies and a further two staff are currently undertaking NVQ level 3 studies. This has not been reflected as an outstanding recommendation as there is evidence the home is working to achieve the required ration of NVQ qualified staff. The registered manager of Francis House also co-ordinates and arranges training for all staff working within the three homes located at the one site. There is a computer system in place that highlights when a staff member is due for an update in training. Recent training undertaken by staff includes: diabetes, epilepsy, health and safety, manual handling etc. A staff member confirmed that they are kept up to date with all mandatory training. Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 19 There have been no new staff employed at the home since the last inspection and there are currently no staff vacancies at the home. It was confirmed that staff receive supervision every two months. The registered manager informed the Inspector that she is aware that they are about one month behind in supervisions. This has not been reflected as a requirement as the registered manager is aware of this shortfall and is taking action to address this. Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 The health, safety and welfare of residents and staff are promoted and protected so far as is reasonably practicable. Staff and residents benefit from a well-run service. EVIDENCE: The manager is experienced and qualified to manage the home. She has completed her NVQ level 4 studies in management and care. She is currently undertaking an NVQ Assessors course. The registered manager also participates in the training provided to staff. Staff and residents were complimentary about the manager at the home. The home has commenced an effective quality assurance and quality monitoring system, as required from the last three inspections. Surveys have been undertaken for residents, relatives and health professionals. This has proved a positive response. There was evidence that feedback had been sought from GP’s, Dentist, District Nurses and Social Workers. There is a designated person within Searchlight Workshops who has taken on the Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 21 responsibility of implementing the quality assurance and quality monitoring on an annual basis. Some policies and procedures were spot-checked and any shortfalls noted have been highlighted in the relevant section of the report. It is recommended that resident’s personal inventories be updated following the Christmas period. The registered manager is also the designated health and safety officer for all three homes located at the one site. It was confirmed that all relevant checks are undertaken and up to date. Staff received fire training from an external company at the end of 2005. Fire drills are undertaken every three to four months and fire alarm testing is completed every week. There were some problems with the hot water system noted. Some taps were delivering water in excess of the recommended 43°C. Water temperatures were variable and fluctuated if the cold water tap was on and then turned off. Some radiators were observed to be unguarded and did not have guaranteed low surface temperatures. It was made an Immediate Requirement that risk assessments are in place for unguarded radiators and for hot water taps delivering hot water above the recommended 43°C. There were windows above ground floor level that were noted to not be restricted. It is required that risk assessments for these windows are undertaken regarding the vulnerability of and risk to residents. Further action must be taken if identified as a high risk to residents. There were suitable records kept of all accidents/incidents. The financial viability of the home was not assessed on this occasion. The home has given no cause of concern regarding financial viability to date. There is appropriate insurance in place. Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X 3 X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 3 X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 1 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 2 X 2 X Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard YA20 YA20 YA20 Regulation 13(2) 13(2) 13(2) Requirement That risk assessments are kept under regular review for those who self medicate. That all medication received and administered at the home can be tracked and accounted for. That a sample signature for all staff administering medication be obtained and stored where accessible. That medication is not double dispensed. Medication must be administered fro the labelled medication provided by the pharmacy. That a restraint policy is developed and implemented. That risk assessments are in place for unguarded radiators and for hot water taps delivering hot water above the recommended 43°C. (Immediate Requirement) That the delivery of fluctuating water temperatures be addressed. That risk assessments for windows not restricted are undertaken. Further action to be undertaken if identified. DS0000059172.V249627.R01.S.doc Timescale for action 15/04/06 31/03/06 31/03/06 4. YA20 13(2) 31/03/06 5. 6. YA23 YA42 13(7 & 8) 13(4) 15/04/06 08/03/06 7. 8. YA42 YA42 13(4) 13(4) 31/05/06 15/04/06 Searchlight Workshops - Francis House Version 5.0 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA9 YA19 YA20 YA23 YA41 Good Practice Recommendations That risk assessments be reviewed when care plans are reviewed. That a checklist be implemented for each individual to clearly identify when visits to health professionals have been undertaken. That hand written MAR charts are checked and signed by two staff who have received medication training. That the POVA procedure is condensed and provides quick, clear guidance for staff and contain the contact details of the appropriate leading authorities. That service users personal inventories are updated following the Christmas period. Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Searchlight Workshops - Francis House DS0000059172.V249627.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!