Inspection on 28/11/06 for St Bede`s Cottage

This inspection was carried out on 28th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Bede`s Cottage 07/12/05

St Bede`s Cottage 12/01/05

St Bede`s Cottage 06/05/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

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

CARE HOME ADULTS 18-65 St Bede`s Cottage Auton Style Bearpark Durham DH7 7AA Lead Inspector Unannounced Inspection 28th November 2006 10:30 St Bede`s Cottage DS0000007503.V321783.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 St Bede`s Cottage DS0000007503.V321783.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. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Bede`s Cottage Address Auton Style Bearpark Durham DH7 7AA 0191 3731124 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) Durham Careline Limited Mrs Anita Ennis Care Home 29 Category(ies) of Learning disability (9), Physical disability (20) registration, with number of places St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Room number 22 can be used to accommodate a person in either the LD or the PD category dependent on need. The increased registration from 28 to 29 residents is for the period up until April 2007, after which St Bede`s Cottage should meet the National Minimum Standards on size of home and unitisation. 7th December 2005 Date of last inspection Brief Description of the Service: St Bedes Cottage is a large old building that has been an adapted and extended. There is car-parking to the front and side but little in the way of a garden area, although the site is large enough to provide one. The home is on a bus route and is close to the local shops. St Bedes has been divided to provide two units for adults between 18 and 65 years. The units are linked but have their own entrances. The St Bedes Unit is for 20 people with physical disabilities, and the Vicarage Unit is for 10 people with learning difficulties. The two units are each staffed separately. The Home provides care and support for people with a wide range of needs. It has good links with care professionals in the community and is active in getting residents any special aids they might need. All the bedrooms are single and have en-suite toilets. The bedrooms are all very individual in size and shape, and are decorated according to the residents choice. There is flat access to both entrances of the home and a lift to all floors. The home charges £378.50 a week for people with learning disabilities and £420-500 a week for people with physical disabilities. This information was provided to CSCI in 2006. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place during two days in November 2006. It was the one inspection planned for this year and was unannounced. The Inspector looked round the building and records in the home. She spoke with four staff and the manager and with 7 residents. One questionnaire was completed by a resident before the inspection. What the service does well: What has improved since the last inspection? What they could do better: When they are giving out as required medication, staff must always record whether they are giving one tablet or two. This is important when people can only have a certain number of tablets a day, because the next staff on duty need to know exactly how many someone has already taken. The manager must continue to check that there are enough care staff on duty at busy times of day. She should also review whether there are enough kitchen and cleaning hours. The National Minimum Standards expect that people under pension age living in care homes should live in groups for no more than 10 people. At the moment, one part of the building is for 20 people with physical disabilities. The owners of the home should continue to work on plans to split this into selfcontained units. They should explain what they plan to do about this to CSCI by April 2007. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 Page 6 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. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed before they are admitted to make sure the home will be able to meet their needs. EVIDENCE: Residents files included assessments by care managers ,which explained their needs. The manager explained how they were asking for a reassessment for a current resident whose needs had changed. This means that the residents care manager would look at whether the home was still able to meet his needs. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents each have a plan, which explains the care they need and how they want to live. Staff know what is in each plan so they can meet residents needs. Residents are asked what they think about life in the home. They can choose to take the risks which are involved in being independent. EVIDENCE: Each resident has a plan which explains what help they need through the course of each day, whether they need help to move around, how they communicate etc .The plans also explain how staff should respond if someone becomes upset or aggressive, to help calm them down. Staff showed that they understand what is in the plans and they said that new staff had to read each persons plan. The manager checks the plans regularly to make sure they are up-to-date and writes a summary, so it is easy to see what has happened recently in someones life. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 Page 10 Each year the home asks everyone what they think about life in the home and uses this information to decide if anything needs to change. The cook described how she asks people if they like the meals. Different people take part in different social activities which shows the home listens to their views. Some residents want to be independent and go out on their own. Sometimes this could be risky for them. When this happens, the home discusses what could go wrong and agrees what it can do to make it less likely something will go wrong. Sometimes this means that staff will offer to go out with someone. Although the home looks after the medication for everyone who is in the home at the moment, they have agreed in the past that a resident could look after their own medicines. They checked that the person could do this safely. Some residents have kettles in their bedrooms so they can make drinks for themselves. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Residents can take part in social and educational activities and are part of the local community. They can keep up contact with their families and sometimes with friends from the area they came from. Residents rights to make choices and decide how they live are respected. Residents are given a healthy diet and can choose what they eat. EVIDENCE: Residents go to local pubs, clubs and restaurants and to the cinema. Some go to special clubs for people with physical disabilities or learning disabilities. Some go to daycare arranged by their care managers. Within the home, some residents are supported to develop or keep up their domestic or self-care skills. One has attended courses at college. Staff and residents talked about regular nights at the local club. The home keeps relatives informed about the welfare of their family members. One care manager said that There is good communication between St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 Page 12 management, staff and relatives which ensures that any arising problems are quickly dealt with. Some residents have very regular contact with their families. When personal relationships between two residents might be harmful to one of them, the home consults with care managers who can look after the interests of both people. Residents said they could choose their own daily routines, and decide whether they wanted to spend time in their rooms or with other people. They said they were treated with respect, as adults. Some use the keys to their rooms and lock them when they go out. The menus kept showed that are meals are varied ,and special diets are catered for. The cook showed a good knowledge of individual needs and had information from a dietician on special diets. There is a choice of dishes for most main meals and the cook provides something else if a resident does not want either of these. Staff have time to help somebody who needs help to eat and they approach this sensitively, using the lounge to give this person privacy at mealtimes. The cook has considerably fewer hours than the council which was previously responsible for inspecting care homes would have recommended. Although the handyman does some heavy cleaning and other staff help as they can, this may make her work tiring and stressful. Records showed that at times, it has been difficult for her to respond to the many different requests for meals. The inspector did not see this as the fault of the cook at all, but it does suggest that the home should look seriously at increasing the catering hours provided. This would help them continue meeting the high standards the cook expects. Residents who commented said that the meals were excellent. Residents weights are checked every month so the home can help them maintain a healthy weight. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provide personal care in a way which meets each service users needs and wishes. The home makes sure that healthcare needs are met. In almost every way, staff look after and give out medication safely. EVIDENCE: The care plans explain the help each person needs through the day and how they like to live. These give the staff the information they need so that they can look after people correctly. Staff showed they knew about the advice in one residents care plan, about how to respond to calm him down, if he became upset. They said that staff were expected to read care plans to make sure they knew what each person needed. They also talked about how new staff were taught to treat residents with respect, as they would want to be treated themselves. Residents confirmed they were treated with respect. Residents described how staff were good at noticing any health problems. One said that staff were very good at looking after his health. During this visit, the Inspector saw staff had called out a doctor again, although a resident had been seen at the hospital the previous night, because they felt the resident still needed medical care. This resident was admitted to hospital that day by the GP. This shows that staff are persistent in obtaining healthcare for residents and use their knowledge of each individual to guide them. Staff get specialist St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 Page 14 advice from psychiatrists, occupational therapists etc when they need to. Records showed that the manager had insisted she received good information on managing a new residents diabetes before he was admitted to the home. Some residents had special equipment to help them stay well, for example mattresses to reduce the risk of pressure sores. Routine healthcare, such as dental care and eye tests is arranged as well. In almost every way, the arrangements for looking after medication and giving it out are good. Staff check medication coming into the home and store it safely. They ask GPs to sign the medication record when they have changed a prescription so that staff can be sure they are giving out medication correctly. Recently, one resident had to have a different dose of his medication every two days and the medication record had been written so that staff would be absolutely clear what they were meant to give. The only error found was that, when the medication record said that a drug could be given as required (for example, paracetemol for pain relief), and one or two pills could be given, staff had not recorded whether one or two pills had been given out. This is important because, when there is a limit to how many pills can be taken each day, staff need to know how many have already been taken. A record showed that they had responded to one residents request to look after her own medication and had put in reasonable safeguards, to check if she was able to do this safely. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can complain and feel that they are listened to. The home does all it can to protect residents from abuse. EVIDENCE: The home has a satisfactory policy, explaining how complaints will be responded to. This has been produced in a picture format to make it easier to understand. Records showed that residents had been able to complain and that the home had responded properly. The manager explained what she had done to prevent problems occurring again. One resident said that when he had complained, the home put it right straight away. Others confirmed that they would feel able to complain if something was wrong. The home keeps proper records of any money they look after for residents. They carry out checks on new staff to help them avoid taking on any one who would be a risk to residents. Most of the staff have had training in understanding what is abuse of residents and what to do if they suspect it is happening. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 a comfortable place to live and meets residents needs. Staff have the training and equipment to keep it safe and hygienic. EVIDENCE: The home consists of two parts; the older part (the Vicarage) is a converted old building which provides a home to people with learning disabilities. The larger part (St Bedes) has been purpose-built as a care home. A lot of work has been done to the older part to bring it up to modern standards. The bedrooms are almost all of a good size and all have an ensuite toilet with either a bathroom or shower. In the newer section, each bedroom has its own ensuite toilet and wash hand basin. All the bedrooms are single. There are extra baths and showers in the building and the owners are putting in an extra bathroom to make it easier for residents to have a choice between a bath or shower. The owners took the opportunity, when building a separate home linked to the existing building, to improve facilities in this home. They provided an extra small lounge and another shower. The two sections of the home each have their own dining and lounge space. The Vicarage building has one lounge/dining room. Where possible, residents St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 Page 17 who prefer to spend time in their room, have been given larger rooms. St Bedes has two dining rooms, a lounge and a conservatory used by smokers. A separate kitchen is available for residents who want to prepare snacks and drinks for themselves. This is a good extra facility as it helps people maintain or develop independence. There has been steady progress in improving facilities in the building and there is a program of regular maintenance. The National Minimum Standards expected that people below pension age should not live in units for more than 10 people. The owners know that they are expected to put plans for separating St Bedes into two units, to achieve this, to CSCI, by 2007. The home seemed clean on the day of inspection. Most staff have had special training in infection control and the others received basic training as part of their induction when they started work. Staff confirmed that they had enough supplies of protective equipment such as gloves and aprons. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have the personal qualities and skills necessary for their work. There are enough care staff are on duty to meet the needs of residents, but the manager must keep checking that there are enough at busy times of day. The home carries out checks on new staff to help them make sure that only suitable people are employed. Staff received training to make sure they can work safely and meet residents needs. EVIDENCE: Residents appreciate the qualities of the staff. They described them as good and friendly, respectful and nice. When the Inspector talked to staff, they described how they were taught to treat residents with respect. 10 of the 18 care staff have achieved the recognised minimum qualification of NVQ 2 in care. This meets the National Minimum Standard of having 50 of the care staff qualified to this level. St Bedes, which is registered for 20 people with physical disabilities, has a minimum of two staff on duty through the waking day (7 am-10 pm). There is one staff awake on duty all night and one person awake on duty until 1 am. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 Page 19 That person is then asleep but on call until 6 am. The night staff can work until 9 am to help people get ready in the mornings. The Vicarage part of the home, which is registered for nine people with learning disabilities, has two care staff on duty through the waking day and one person awake on duty at night. As well as these staff, two staff are on duty each day for two hours in the afternoon, to help provide activities and take residents out into the community. Another nine hours a week are also provided. The manager said that staff work extra hours so that they can go with residents to hospital appointments etc without reducing the number of staff on duty in the home. These hours were not showing on the duty rota and the manager must make sure they are recorded on it, to give a full picture of staffing in the home. Staffing levels seem generally satisfactory to meet residents needs, taking into account that some residents in the Vicarage go out for day care and a number of residents in St Bedes are fairly independent in their personal care. Staff said that the busiest time is the morning and the manager will need to continue to check if extra staff are needed at this time. Residents said that the staff were able to come reasonably quickly when they needed help, are always on the go but not too busy. As well as care staff, the home employs an administrator and handyman (shared with the home next door) and a cleaner. The cleaner had recently left but other staff were covering the cleaning rota. The hours provided are considerably fewer than the council which previously inspected care homes would have recommended. The home should review whether there are enough hours to keep the home well cared for. The records of two staff who have started work recently showed that the home had obtained two or three references, to find out if they were suitable people to work in the home. The manager had carried out a Criminal Records Bureau and Protection of Vulnerable Adults List check to find out whether people had anything in their past which would make them unsuitable to work with vulnerable adults. All the staff have had training in first aid and safe moving and handling. Most have had training in the protection of vulnerable adults and in preventing and responding to fires. The rest will receive this training in the near future. Most staff have had training in challenging behaviour but a number of care staff have not had training in food hygiene. Whenever possible, the home makes use of training provided by specialist organisations and nurses, such as training about diabetes, epilepsy and Parkinsons disease. This helps staff learn more about particular conditions residents may have. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 manager is suitably qualified and experienced to carry out her job. The home has a system for checking on the quality of the service it provides, which includes finding out what residents, relatives and care managers think of it. The home is a safe place to live and work. EVIDENCE: The manager has a City and Guilds qualification of Advanced Management in Care and an NVQ 4 in care which are recognised qualifications for care home managers. She has managed the home for approximately 7 years and continues to update her training. She provides clear expectations for staff and seems to have the confidence of residents-one described her as fantastic. Each year the home carries out a survey of residents, relatives and care managers to find out what they think of the home. The manager described how she followed up any negative comments to make sure that the home did St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 Page 21 better. The records of complaints showed that she also uses these in a positive way to make sure that the standard of care meets the expectations of relatives etc. This years survey has recently been done and the results were overwhelmingly positive. There is an established system to make sure that equipment, the heating system, lift and hoists are regularly serviced. The fire safety system is regularly checked and fire drills carried out. The home carried out an assessment of fire risks and how they can prevent fires starting, and reviewed this assessment of this summer to make sure it was up-to-date. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 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 Standard YA20 Regulation 13 Requirement When either one or two tablets can be given as as required medication, staff must record which they have given out. The manager must review whether enough care staff are on duty during busy times of day. Timescale for action 29/11/06 2 YA33 18 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA24 YA33 Good Practice Recommendations Plans to create separate units for ten or fewer service users should be sent to CSCI by April 2007. The manager should check whether there are enough kitchen and cleaning hours provided. St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 St Bede`s Cottage DS0000007503.V321783.R01.S.doc Version 5.2 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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