Inspection on 11/01/06 for St Mark`s Road Care Home - Block A

This inspection was carried out on 11th January 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Mark`s Road Care Home - Block... 10/06/09

St Mark`s Road Care Home - Block... 06/10/08

St Mark`s Road Care Home - Block... 22/10/07

St Mark`s Road Care Home - Block... 02/08/06

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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 St Mark`s Road Care Home - Block A 24 St Mark`s Road Derby DE21 6AH Lead Inspector Claire Williams Unannounced Inspection 11th January 2006 08:30a St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Mark`s Road Care Home - Block A Address 24 St Mark`s Road Derby DE21 6AH 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) 01225 444 596 The Robinia Group PLC Karen Mary Bridge Care Home 8 Category(ies) of Learning disability (8) registration, with number of places St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the first inspection since the home was registered. Brief Description of the Service: Robina Care Group is the responsible provider for 24 St Marks Road. The home is located on the same site as another home owned by this organisation. The same Registered Manager is responsible for both homes. The home was registered in July 2005 to provide personal care and accommodation for up to 8 people in the category of learning disability aged between 18 and 65 years of age. The home is situated in Chaddensden just outside Derby City centre and is close to local amenities. A car park in available at the front of the premises and a garden at the rear. The home was purpose built and provides a spacious environment with all rooms being of single occupancy with en-suite shower facilities. The home provides places for individuals who are of a younger age group. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection since the home was registered in July 2005. The inspection was unannounced and commenced at 8.30am and lasted 7 hours. The inspector assessed all of the required key standards as identified by The Commission for Social Care Inspection. The inspector spent time examining the paperwork, staff interactions, staff files and a tour of the building was undertaken. Time was spent talking to both staff and the individuals living at the home. The Registered Manager and the newly appointed deputy both assisted the inspector with the inspection. What the service does well: What has improved since the last inspection? This is the first inspection since the home was registered with the Commission for Social Care Inspection. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 6 What they could do better: 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. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, and 4 Information and opportunities are provided to enable individuals to make an informed choice about moving into the home. Assessments are undertaken to ensure individual needs and aspirations are met. EVIDENCE: Individuals are provided with a copy of the Statement of Purpose and service user guide, which enables them to have the information they require to make an informed choice about where to live, and to be informed about the facilities available at this home. The inspector examined the admission process for two individuals. Both files contained comprehensive Community Care Assessments, which have been completed by the sponsoring Local Authority. There was evidence in the files to support that the Registered Manager and a delegate from the home had visited the individuals prior to their admission and completed pre-placement assessments. However the detail varied between the files in terms of the information gathered from these visits and the completion of the assessments. One assessment was completed in full but another was only completed in brief and was not signed or dated by the person undertaking the assessment. The inspector spoke with an individual who moved into the home a month after the home opened. The inspector was informed that trial visits was facilitated in order to enable the individual to “test drive” the home and to meet the staff team and fellow tenants. However limited evidence was available in one file to St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 9 support the visits undertaken and outcomes, however there was evidence in the second file to support that trial visits was facilitated. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 10 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, and 10 Care files do reflect individual aspirations and needs, but service plans need to be in more detail. Individuals are consulted about their lives and about the running of the home. EVIDENCE: The inspector examined the files of two individuals, one who had recently moved into the home and one who has lived in the home for a period of time. Both files contained personal service plans that have been developed from the pre-admission information. The topics covered within these plans were varied but included aspects of personal and healthcare needs specific to individuals. The plans varied in detail between the two files. One was completed in adequate detail but the second one was brief and gave limited information on how the individual should be supported in their daily care. The personal service plan links in with the Aims and Objectives, which are compiled based on the individuals needs, and aspirations. The individual’s keyworker are responsible for completing progress reports on a monthly basis for each objective identified, and there was evidence to support that this was being undertaken. One of individuals living at the home is able to be involved in the development of her plan, but there was no evidence to support that she had been consulted. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 11 Both files contained a variety of Risk assessments that indicated key areas of concern and ways in which staff could minimise or eliminate any problems arising from these risks. On file did contain a separate Moving and Handling risk assessment, but this was incorporated into the generic risk assessment for the second individual, and only a brief statement was recorded. One file contained an information sheet concerning the behaviour that an individual could present, which could be deemed as challenging to the service and the staff team. Within this information was a list of key triggers that the individual may present before any challenging behaviour may occur. Staff complete behaviour analysis forms to record information when significant incidents occur. From discussions held and observations made by the inspector it was evident that individuals are actively encouraged to be self-managing and independent in their lives and observations confirmed that service users are consulted on a daily basis concerning aspects of their routine. Individuals are aware that information is held about them, and that the files are always locked away securely. For individuals that are not able to verbalise their decisions and preferences a core staff team including their keyworker meet on a monthly basis in order to discuss any issues and make any required decisions. Records are maintained of these meetings and any decisions made and families are involved in this process if the issue requires their involvement. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 12 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, 13, 14, 15,16, and 17 Individuals living in the home have access to varied opportunities, and life experiences in order to develop independent living skills and try new experiences. Contact with family and friends is promoted and supported. Individual routines within the home are respected EVIDENCE: The inspector spent some time with one individual and discussed what they do within the week. The inspector was informed that she has developed a weekly activities planner with the activities co-ordinator that is employed to work at both of the homes on the same site. Within this programme there is time allocated for leisure activities of the individual’s choice, and development activities to enable the individual to develop independent living skills. She confirmed that the staff team do provide access to community facilities and socially inclusive activities. This individual confirmed that she is encouraged to be self-managing and is in the process of having discussions with the Registered Manager about the possibility of using equipment independently in order to undertake transfers from her wheelchair to the shower, this is to enable her to be less dependent on staff support. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 13 A weekly planner of activities is completed for all individuals living in the home, and each individual has structured daily activities. At the time of the inspection a group of people went on an outing to Leicester space centre in the minibus that is provided for the home. The activities co-ordinator is in the process of trying to access college courses for some of the people living at the home. The Registered Manager confirmed to the inspector that discussions are now taking place to ascertain where people would like to go for a short break or holiday later in the year. Discussion and observation confirmed that the daily routines of the home are flexible and promote individual’s independence, choice, and freedom of movement, in accordance with their support needs. Individuals confirmed that contact with their family and friends are encouraged by the staff team, and the records confirmed this. Discussions and observations confirmed that individuals are supported with their dietary requirements. Individuals are supported to choose their meal on a daily basis are encouraged to prepare their meals. Some individuals require their food to be liquidised and this is done separately for each food item, which is good practice. Staff were observed supporting individuals to eat their food in a relaxed and dignified manner. The people living at the home have opportunities to go food shopping with staff members. Although fridge and freezer temperatures were monitored, records were not always completed twice daily. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, and 20 Service users are supported in accordance with their individual needs and preferences in all aspects of their health and personal care needs. Medication was well managed in the home. EVIDENCE: The personal service plans are completed from the individual’s perspective and therefore information is recorded on how individuals prefer to be supported in elements of personal care. Individual cultural requirements are recorded and implemented as part of their care plan. Individuals spoken with confirmed that the staff team supported them in their personal care tasks in a manner, which is in accordance with their individual preferences. The examination of records and discussions held with individuals confirmed that their physical and emotional health needs were being met at the home. Individuals are supported to attend health care appointments by the staff team, and information about the outcomes and any required action is recorded in the medical files for that person. There is also evidence to support that families are informed about the outcomes of visits. The inspector examined the medication cabinet and associated documentation, and observed the staff practices. It is the responsibility of the Team leaders to administer medicines and some have now undertaken a day course delivered by boots in “Safe handling of medicines”. Another course has been arranged St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 15 with another company for those individuals who require this training. Staff members are only allowed to administer medication following this training. The Registered Manager informed the inspector that she would be completing medication competency assessments on the team leaders to assess their practices. Generally the medication practices were satisfactory, apart from staff not using the code system to identify why a medication is not administered, but explanations were recorded on the reverse of the Medication Administration Record. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Satisfactory complaints and adult protection procedures are in place in order to safeguard service users. EVIDENCE: A complaints procedure and recording system are in place and an accessible procedure displayed within the home. The Registered Manager amended the format for recording complaints received during the inspection and it now covers all of the required areas. The home has not received any complaints since becoming operational. The home have received a compliment from a family member commending the staff team on how “keen they were to find out the likes and dislikes and the support needs” of an individual who has recently moved into the home. The relative also stated how well and happy their daughter seems on visits and the positive experiences she already has had for example, going ice-skating. The relative stated that she is always made to feel welcome when she visits the home. A Vulnerable Adults policy was in place, that’s refers to the local authority procedures. At the time of the inspection a copy of the local procedures was not available. The inspector agreed to send a copy of these to the home. It was evident from discussions with both management and the staff that all had an awareness of the procedures that need to be followed in the event of an incident occurring. The Registered Manager confirmed that all staff have attended adult protection training apart from 3 who are booked on the next available course. The inspector was informed that there have been no incidents at the home this year. The inspector checked the management of individual’s finances. All money held in safekeeping was held separately in individual’s bags. The amounts held St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 17 cross-referenced to the transaction sheets and there was evidence of receipts for purchases made on behalf of individuals living in the home. A financial management procedure is in place but was not examined on this occasion. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 18 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, 26, 27, 29, and 30 The home is equipped, furnished and maintained to a satisfactory standard and offers homely and spacious facilities for individuals to enjoy. EVIDENCE: The home is decorated to reflect a homely domestic environment. The inspector was invited to look at bedrooms by the individuals living at the home. The bedrooms was personalised to reflect the interests and preferences of that individual. All bedrooms are of single occupancy and have shower ensuite facilities. Each room is also fitted with a ceiling-tracking hoist to assist with the moving and handling of individuals with physical disabilities. The inspector was informed that this tracking system has been recently replaced due to problems with the previous system not being smooth and working properly. One of the people living at the home who use this equipment confirmed that the new system “is much better”. Other aids and adaptations to assist with individual’s mobility were also provided including specialist baths and hoists. Following a discussion with one individual it was highlighted that additional aids are required in order to enable her to open her bedroom door, which she is currently having difficulties with. The possibility of this was discussed with the Registered Manager. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 19 The kitchen area is accessible for individuals who use wheelchairs, and an accessible worktop, is provided enabling individuals to make their own meals and drinks. The garden and outside areas are all accessible for wheelchairs and the home is currently developing the garden areas. The inspector observed service users being supported to use the outside areas. Individuals at this home have access to a sensory room that is currently being developed. The home was found to be clean and hygienic at the time of the inspection. The care home is located on a site with another care home owed by Robinia. The home does not have a number located on the front door making it difficult for external people to locate the address of the home should they need to visit. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 20 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): 31, 32, 34, 35, and 36 The deployment and numbers of staff appeared satisfactory to meet the needs of the people living at the home. A mixture of staff that are competent in their roles support the people living at the home. EVIDENCE: A copy of the duty rota for week ending 7/1/06 was provided. The staffing levels provided enabled staff to provide some one to one support as well as group support individuals both inside and outside the home. Additional staff members are on duty to provide support for any planned activities or when the needs of the individuals require additional support Staff spoken with showed a good awareness of individual support needs and their aspirations. Feedback was obtained from individuals and the following comments were made, “the staff are great and supportive and helpful”, and “friendly and nice”. Individuals felt that the staff team are able to meet their support needs, and that they assist them to have positive opportunities in their lives. The inspector examined three staff files, one of these was for a new employee. All files contained all of the required documentation and were in good order. However not all of the files contained an applicants full employment history as required by the amended Care Home Regulations 2003. The Registered Manager confirmed that staff have been given the required policies and St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 21 procedures and a copy of the General Social Care Council Code of conduct but the staff have not signed to verify receipt of these documents. Staff spoken to confirmed their access to regular training and development opportunities, and records of training supported this. Staff confirmed that they receive regular supervision from the Registered Manager and records confirmed this. All new staff members undertake an induction that meets the requirements of Skills for life specifications. However not all of the files contained certificates as evidence of all of the training undertaken. The inspector was informed that there are 7 staff members who are currently undertaking a National Vocational Qualification (NVQ) level 2 or above, and that 2 staff have already achieved this award. The Registered Manager confirmed that more staff would be enrolled on the next intake for this course. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 22 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, 38, 39, and 42 The Registered Manager has a good understanding of the areas, which need to be developed within the home. The home is managed in the best interests of the individuals living there. EVIDENCE: The Registered Manager is currently undertaking an NVQ level 4 in management and care. She has responsibility for two homes located on the same site. In response to some restructuring of the senior roles the Registered Manager now has the support from a newly appointed deputy who previously worked at another home in the capacity as a Registered Manager. This will be mean additional support for both the Registered Manager and the staff team in both homes. The home is also currently interviewing for an addition team leader so that one can be available on each shift pattern. The staff members and individuals spoken with that live in this home, stated that they have found the Registered Manager to be approachable and supportive. The deputy stated how the team has welcomed her and observations confirmed that positive working relationships have already been St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 23 made. The home now has a full occupancy and the Registered Manager is now looking to develop the home and complete a development plan of what she wants to achieve in the next 12 months. Part of this plan should include the development of questionnaires in order to obtain feedback from the people living in the home, their families or representatives. The Health and Safety systems in the home were satisfactory and are still in date as the home has been in operation for 6 months. The staff undertake health and safety audits of the building and complete records. There was evidence to support that Fire tests and checks are undertaken and records maintained. There was evidence to support that a representative from the organisation regularly undertakes visits to the home in accordance with the requirements of regulation 26. St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 24 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 2 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 x ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 X X 3 X St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 25 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 (1) (a) Requirement The Registered Persons must ensure that when pre-placement assessments are undertaken, they are completed in full, dated and signed. The Registered Persons must ensure that individual’s service plans are completed in detail to enable the staff team to deliver appropriate support. The Registered Persons must ensure that individuals are consulted and included in the development of their plan. The Registered Persons must complete a separate Moving and Handling Risk Assessment in order to make it clear what support individuals require in their files. The Registered Persons must ensure that fridge and freezer temperatures are monitored and recorded twice daily. The Registered Persons must ensure that the staff team use the appropriate codes to record why medication has not been administered. The Registered Persons must DS0000063066.V275848.R01.S.doc Timescale for action 01/04/06 2 YA6 15 (1) 01/04/06 3 YA6 14 (1) (d) 01/04/06 4 YA9 12 (1) (a) 01/04/06 5 YA17 16 (j) 01/03/06 6 YA20 13 (2) 01/04/06 7 YA29 23 (2) (n) 01/04/06 Page 26 St Mark`s Road Care Home - Block A Version 5.1 8 YA34 19 (b) (i) 9 YA35 19 (5) (b) look into the provision of additional aids and adaptations in order to enable an individual living at the home to be able to open the bedroom door independently. The Registered Persons must ensure a full employment history is obtained for all applicants and newly appointed staff The Registered Persons must ensure that copies of certificates are available on staff files of the training undertaken. 01/04/06 01/04/06 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 3 Refer to Standard YA6 YA6 YA13 Good Practice Recommendations The Registered Persons should ensure that all documentation completed for services users is signed and dated and completed in full. The Registered Manager should ensure that personal service plans are dated when completed. The Registered Manager should ensure that indivduals likes, dislikes, and hobbies are reflected in individual personal service plans in addition to the sheet in their diary. The Registered Persons should contact a District Nurse to discuss the possible use of Tissue Viability assessments in order to monitor service users pressure areas. The Registered Manager should ensure the medication signature sample sheet is replaced. The Registered Persons should consider putting a number on the front door to enable external people to be able to identify the home. 4 5 6 YA19 YA20 YA24 St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 St Mark`s Road Care Home - Block A DS0000063066.V275848.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!