Inspection on 12/12/06 for Shalom

This inspection was carried out on 12th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shalom 21/02/06

Shalom 15/08/05

Shalom 27/01/05

Shalom 17/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Shalom 1 Pen Close Manor Lane, Baydon Swindon Wiltshire SN8 2JD Lead Inspector Bernard McDonald Unannounced Inspection 12th December 2006 09:00 Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shalom Address 1 Pen Close Manor Lane, Baydon Swindon Wiltshire SN8 2JD 01672 541351 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) White Horse Care Trust Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 Brief Description of the Service: Shalom is a large detached bungalow offering accommodation and personal care to four people with Learning Disabilities. The home is one of a number of homes owned by the White Horse Care Trust, a voluntary organisation. The home was registered in July 2002 and is situated in the village of Baydon close to the Berkshire border, some 8 miles north east of Marlborough. The nearest towns to the home are Marlborough and Swindon. The property is located within easy access of local amenities. Service users are provided with their own bedrooms, which are individually decorated and furnished. There are adequate parking facilities to the front of the building. There is also a patio area to the front of the property and a grassed area to the rear of the property, which are well maintained and easily accessible. The service users receive support throughout the day from a permanent staff team. There are three care staff on duty throughout the waking day. The home has one waking and one sleeping member of night staff. The range of fees for the service is £1142.47 to £1448.27 per week. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six and three quarter hours. A tour of the building was made and all areas of the home including all service users bedrooms were seen. We met with all service users but were unable to communicate effectively with them to obtain their views on the service they receive. In addition four members of staff were spoken to in private. The acting manager was also available to assist throughout the majority of our site visit. As part of our inspection, comment cards were sent to all service users, their representative’s, health care professionals and placing authorities. Four care plans were examined two in detail. In addition medication records, staff recruitment files, training records, health and safety documents and a sample of risk assessments were also examined. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: Service users benefit from a high standard of accommodation which is comfortably furnished and well maintained. The home is making every effort to ensure service users have information in a format suited to their needs. This includes the statement of purpose, service user guide and complaint procedure, which have been produced in a format using pictures and text. In addition there is evidence to demonstrate staff have discussed the contents of these documents with service users to enable them to understand the contents. The home is ensuring service users health care needs were being met and that they had access to wide range of health care services. Medication is being safely managed. Observations made during the site visit found staff had an awareness of how service users make a choice and communication tools are in place to assist staff to understand service users gestures and sounds. A comment card received from a health care professional confirmed general satisfaction with the care provided to their “patient” Quality assurance systems are in place, which seek the views of service users, their representatives and relevant stakeholders. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: More attention needs to be given to ensure the service users care plans fully reflect their needs and the care and support they receive. Service users risk assessments need to be kept under review to ensure the assessment remains appropriate and do not unnecessarily impact on the service users rights or freedom. The general standard of record keeping in relation to service users activities and access to the local and wider community needs to be improved. This would enable the home to audit service users participation in these activites and ensure they remain relevant and suited to their needs. There has been no registered manager at the home for over twelve months. The registered person must now make every effort to appoint a manager and ensure an application for registration is made to the Commission. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 8 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 Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedures have not been inspected but there are clear procedures in place should they be required. The home is making every effort to ensure service users have sufficient information about the service including the terms and conditions of their stay. EVIDENCE: The home has not admitted any service users since the last inspection. All service users have lived together for over eleven years. Placements remain appropriate and it is anticipated service users will continue to live at the home on a long-term basis. The homes statement of purpose details the admission procedure and specifies the home does not admit any emergency placements. The procedure outlines that a full assessment of the service user needs must be received to enable the service determine whether their needs could be met at the home. Examination of service users records show that each person has been provided with a service user guide. Due to service users communication difficulties the guide has been developed using symbols and text. At the front of each file Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 10 there is statement that staff have explained the contents of the document to the service user and what their reaction was to receiving this information. Each service user has an individual contract, which specifies room to be occupied and the cost of their stay. Service users are notified in writing of the annual increase in fees and the amount of their contribution. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users changing needs are not fully reflected in their care plan. However service users are supported to make decisions and choices but more attention needs to be given to ensure risks associated with their care are kept under review. EVIDENCE: The care files of all service users were examined. Two care files were examined in close detail. Since the last inspection the home has developed a care plan review checklist for staff to sign. This new procedure ensures staff have read and understood that a care review has taken place and they are aware of any changes. The care plan is split into a support plan and an individual plan. The support plan documents the support service users need in relation to communication, choice, culture, health and wellbeing, keeping safe, relationships and work and leisure. The individual plan details service user likes, dislikes, strengths, needs Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 12 and goals. Records examined showed service users are involved in their care review. Where appropriate a relative, or the service users representative also attends the meeting. Comment cards received from the relatives of service user confirmed they were kept informed of important matters. Of the two care files examined in detail there was no evidence to demonstrate any progress had been made in achieving goals set out in the individual plan. One service user with deteriorating mental health needs had their care plan reviewed every three months. However the care plan and support plan had not been updated to reflect their changing needs. Discussion with the acting manager and support workers confirmed that opportunities to enable the service users to engage in the local and wider community are now more spontaneous and responsive to how the service users was feeling on the day. This action needs to be incorporated into the service users care plan to avoid inconsistency in the way care is provided. Following a requirement at the last inspection risk assessments on specialist interventions such as the regurgitation of food and management of behaviour had been reviewed. However service users personal risk assessment had not been reviewed in the past year. The manager reported this was primarily due to staff illness. Discussion with the area care manager confirmed personal risk assessments are currently being updated. The support plan has information on how service users are offered choice. Discussion with staff confirmed service users are able to choose when to get up and go to bed, what to eat and what to wear. Staff demonstrated a good awareness of how service users make a choice. For example service users are offered a choice of items to wear and then indicate by gestures, which they prefer. Communication tools are in place in the support plan to assist staff to understand service users gestures and sounds. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home needs to improve the standard of recording to fully evidence service users opportunities for personal development and access to appropriate leisure activities. Visitors are made to feel welcome. The home provides a healthy diet. EVIDENCE: Service users have unrestricted access to all parts of the home other than the kitchen area. Service users are encouraged to keep their room tidy, but this is more by choice rather than part of their care plan. The home has transport available to ensure service users are able to access the local and wider community. Discussion with staff indicated that opportunities are provided to enable service users to visit the local public house, go out for meals, and go out shopping in addition to various day trips. Each service users has a weekly activity planner, which support workers and Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 14 the acting manager confirmed service users regularly attended. However it was difficult to fully evidence what activities service users did attend. Daily records did not evidence what activites service users engaged in. Records did not show whether service users enjoyed participating in the activity and to what extent they were involved in the activity. The care plan of one service user specified they should access the community more, yet there was little evidence to show whether this had been achieved. Observations made during the inspection showed staff taking service users out, which would indicate it is poor recording of activities service users participate in rather than limited opportunities. The homes calendar did show one service user had been away with staff on holiday this year. There is a multi cultural staff team that reflects the Trusts commitment as an equal opportunity employer. Service users can, if they wish, attend a Church service though none have currently chosen to. Service users spiritual needs have been identified as part of the care plan. Discussion with the acting manager confirmed visitors are welcome at anytime. Feedback in relatives comment cards confirmed they are made to feel welcome and can visit when they want. The acting manager confirmed that if required staff will support service users to visit their relatives at their own home. One service user has regular contact with their relative and goes home on occasional weekends. The records of meals served at the home were examined. The menu is normally planned two weeks in advance. Service users are not routinely offered a choice but support staff confirmed that if a service user were to refuse a meal an alternative of equal nutritional value would be offered. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is making every effort to ensure service users health care needs are met and they receive support in a way they prefer. Policies, procedures and training are in place to ensure medication is safely administered. EVIDENCE: A feature of the service is that male staff have been employed giving male service users the opportunity to receive personal care from a person of the same gender. Male support staff are not required to provide intimate care to female service users. There is a relaxed atmosphere in the home and routines are flexible and responsive to the needs and choices of service users. Service users health care needs are recorded in their care plan. Records show that service users have access to the dietician, district nurse, physiotherapy, hydrotherapy and domiciliary dental and optician services. Each service user has a health action plan. Service users are registered with the local health care Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 16 practice. A comment card received from a health care professional confirmed general satisfaction with the care provided to their “patient” All staff who have responsibility for administering medication have received training in the safe administration of medication. In addition staff are individually trained in the administration of diazepam and medazolam. Certificates to demonstrate competency in administering medication were available in the home. As a matter of good practice medication competency training is updated every twelve months. All medication is held secure in the home and examination of a sample of the medication records showed one gap in the records of medication administered to service users. A separate record is kept of medication received at the home and returned to the pharmacy. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is making every effort to ensure service users views are listened to and they are protected from abuse. EVIDENCE: Since the last inspection we have received one anonymous complaint. This was sent to the registered provider to investigate using the homes complaints procedure. The outcome of the investigation found the complaint could not be substantiated. Examination of the homes complaint record showed no other complaints had been received. Since the last inspection the White Horse Care Trust in partnership with service users have developed a video to enable service users to more fully understand how they can make a complaint. While this is seen as good practice, service users have not yet been able to view the recording, as the home’s video is not working. Policies and procedures are in place to protect service users from abuse. A whistle blowing policy is also in place should staff wish to use it. Discussion with support staff demonstrated good understanding of what action they would take if they were concerned about the welfare of service users. Staff training records showed the majority of staff had completed abuse awareness training. A sample of the records relating to money being held on behalf of service users Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 18 was examined. The records demonstrated service users money was being accurately recorded. As a matter of good practice the acting manager completes a weekly audit to ensure records are accurate and up to date. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides service users with a high standard of accommodation, which is clean and comfortably furnished. EVIDENCE: All communal living areas and service users bedrooms were seen. The home was clean and tidy and furnishings were of a good standard. The accommodation comprises of a large communal living area and separate dining room. Service users have single bedroom accommodation and two bedrooms had recently been decorated. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 20 The laundry area is accessed through the kitchen. The laundry floors and walls are easily cleanable to help reduce the risk of infection. However the home has yet to purchase red alginate bags, which would help minimise the handling of soiled or infected linen. The home has a copy of the Health Protection Agency infection control guidelines and the majority of staff had completed infection control training. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is ensuring safe recruitment practices are followed and that staff receive training and supervision appropriate for their role. NVQ training remains underdeveloped. EVIDENCE: Since the last inspection three permanent members of staff have been appointed. Examination of their recruitment records showed the home is ensuring they had received a satisfactory Criminal Records Bureau (CRB) check and a Protection of Vulnerable Adults (POVA) check prior to the staff commencing work. In addition two written references and proof of identity had also been received. Discussion with two staff recently appointed confirmed they had been able to shadow a more experience member of staff as part of their induction. The staff also confirmed their names had been put forward for the Learning Disability Award Framework (LDAF) training as part of their induction. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 22 There is a staff-training plan, which is linked to the homes statement of purpose. This needs to be updated to be a true reflection of the training staff had received and enable the acting manager to readily identify gaps in staff training needs. From discussion with staff and examination of records it is evident that staff are able to access training appropriate for the work they perform. This includes training in the role of the key worker, John O’Brien’s principles, the ageing process and personal relationships. Less developed is National Vocational Qualification (NVQ) training. At the present time only four members of staff have completed the award. The manager commented that staff training needs are identified as part of individual supervision. The frequency of these meetings has improved since the last inspection. The Trust has now commenced Equality and Diversity training for staff. Two staff are currently completing the course, which is run over twelve weeks and is facilitated by the local college. Discussion with one member of staff who is completing the course stated, “It is a good course which is thought provoking and should improve practice”. They went on to say, “ It makes you step back and think more about how different people are”. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The acting manager has made every effort to ensure service users continue to live in a safe environment, which is run for their benefit. However the continued absence of a permanent manager who is registered by the Commission needs to be addressed. There is an effective quality assurance system in place. EVIDENCE: There continues to be no registered manager in post. The acting manager has worked in this capacity for over twelve months and stated it is their intention to apply for registration with the Commission. The acting manager confirmed she is currently working towards NVQ 4 in care, which she hopes to complete in the summer. Since the last inspection the acting manager has been Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 24 allocated extra hours off the rota to enable her sufficient time to complete her management responsibilities. In partnership with the Trust the home has distributed quality satisfaction surveys to relatives and staff. The acting manager stated the views of service users are obtained through observations, signs and gestures. The outcomes of the surveys were available in the home together with the homes action plan from last years survey. The overall outcome of the survey showed that the relatives and representatives of service users were generally satisfied with the care and facilities at the home. This view was also endorsed in the comment cards we received from relatives and health care professionals. The home continues to complete a monthly health and safety audit, which was evidenced by records held at the home. This is in addition to the annual health and safety audit, which is completed by an independent company. The acting manager reported that this assessment has recently taken place but the report has not yet been received. To ensure service users safety radiators are guarded and hot water is regulated close to 43c. Legionella checks are completed every three months. There is a large file, which contains a substantial number of risk assessments. The majority of these had not been reviewed in the past year and it was difficult to evidence whether they remain appropriate. The acting manager stated that one member of staff is now responsible for ensuring all risk assessments are updated and a new template has been developed to support this work. Fire safety records were examined. Records demonstrated the home has completed a fire safety risk assessment and has improved the frequency of fire safety drills. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 26 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. Standard YA6 Regulation 15(1)(b) Requirement Timescale for action 01/02/07 2. YA9 3. YA37 4. YA42 The registered person must ensure the service user care plan fully reflects the needs of service users. 13(4)(a)(b)(c) The registered person must ensure service users personal risk assessments are reviewed at least annually or earlier if the risk to the service user changes. 8(1)(a) The registered person must appoint a manager and ensure an application for registration is made to the Commission. 13(4)(c) The registered person must ensure unnecessary risks are identified and ensure health and safety risk assessments are reviewed at least annually or earlier if the risk to the service user changes. 01/04/07 01/04/07 01/04/07 Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA12 YA30 YA32 Good Practice Recommendations The registered person should ensure service user access and their involvement in leisure and social activities are recorded. The registered person should consider using red alginate bags for soiled or infected linen. The registered person should consider how it would ensure at least 50 of staff are trained to a minimum NVQ level 2. Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shalom DS0000028445.V322195.R01.S.doc Version 5.2 Page 29 - 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!