CARE HOME ADULTS 18-65
St Marks House Brook Street Lye Stourbridge West Midlands DY9 8SE Lead Inspector
Mrs Jean Edwards Unannounced Inspection 30th November 2005 09:40 St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service St Marks House Address Brook Street Lye Stourbridge West Midlands DY9 8SE 01384 896654 NONE 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) Chadd Housing Association Mrs Ann Siddle Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16), Old age, not falling within any of places other category (9) St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up to 9 OP and up to 16 MD Date of last inspection 21/06/05 Brief Description of the Service: St Marks House is a purpose built home, opened 17 years ago, owned and supported by the Church Housing Association of Dudley & District (CHADD). It is located in Lye, in an area which is part residential and part light industry. There are local amenities nearby and the Home is within walking distance of several good bus services to nearby towns. The frontage of the Home has ample car-parking facilities; to the rear there are well-maintained gardens, with mature trees, shrubs, flowerbeds and patio areas. The interior of the Home appears bright and airy, with domestic and Homely fixtures and fittings. The Home provides 16 single en suite bedrooms for people over 50 years of age, who have various forms of mental ill health. The Home provides four bathing / showering facilities, which are satisfactory to meet the amended National Minimum Standards for Younger Adults. There are a number of seating areas around the Home including a well-used conservatory extension, a quiet room and designated smoking lounge. The Home has a stable staff team of 23 people including the Registered Manager. St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection has taken place over one weekday. The purpose of this inspection visit is to assess progress towards meeting the national minimum standards and the homes progress to improve areas identified at previous inspection visits. A range of inspection methods has been used to make judgements and obtain evidence, which include: discussions with the Registered Manager, the senior care officer, residents and other staff. A number of records and documents have been examined. Other information was gathered prior to the inspection visit, from the reports of visits undertaken by the committee representatives and an action plan submitted by the home following the last inspection. During the visit the inspector spoke to residents who are currently living at the home, with longer discussions taking place with 2 residents whose care was looked at in depth. The home’s senior staff and administrator took an active part in the inspection process and the majority of staff have been spoken with during the visit. A brief tour of the building has taken place, looking at the laundry, bathing facilities, communal areas of the home and a sample of residents’ bedrooms, with their permission. What the service does well:
The registered manager has responded to the previous inspection report with a comprehensive action plan, giving dates for the required improvements to be put into place. The registered manager continues to demonstrate commitment to making sure that improvements happen. Residents are encouraged to treat St Marks as their own home and they can be as independent as they wish. Residents can make their own choices and have their own meetings. Notes of the meetings can be seen on the residents’ notice board. A range of topics is discussed, with opinions freely aired about the running of the home. The topics at a recent meeting included the last CSCI inspection report, a boat trip and household matters. Residents are able to go on an annual holiday if they wish; this year the choice was a week in Sand Bay at the end of June. The majority of residents chose to go on the holiday, supported by volunteers from the staff group. People have spoke of their enjoyable times during the holiday. Five residents chose not to have a week away and opted to stay at home at St Mark’s. Arrangements for the Christmas celebrations are well advanced. A Christmas fayre is going to take place on 3 December 2005 and other events include
St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 6 Christmas card writing, calendar making and cooking sessions - making shortbread and cakes. St Marks continues to have a stable group of staff who have worked at the home for a long time and know the residents well. They are caring, committed and flexible, often willing to work extra shifts, especially to support residents with their leisure time activities. There is a warm and friendly relationship between staff and residents, with lots of friendly chatter during the visit. Members of staff continue to demonstrate a dedicated approach to their work, with a good knowledge of residents’ needs, likes and dislikes. St Mark’s continues to maintain excellent standards of cleanliness. The home is tidy, homely and comfortable. Although the home does not employ domestic staff everyone including the registered manager is involved in cleaning duties. Residents state that the standard of cleaning is very good and they are generally pleased to be involved in daily tasks, especially their own bedrooms, seeing this as a way to keep their independence. This inspection has been conducted with full co-operation of the Registered Manager, staff and residents. The atmosphere through out the inspection has been relaxed and friendly. The Inspector would like to thank staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection?
The home has a comprehensive medication system, which encourages the residents to take responsibility for their own medication wherever possible. At the last inspection visit a small number of minor improvements were needed, which have now been put in place. The home follows a rigorous system to select and recruit new staff and a number of improvements have been made so that all stages of the recruitment process are always fully completed. All new members of staff have a very detailed in house induction to make sure they know how the home works and how residents prefer to be supported. There is continuing support for all members of staff through a system of formal supervision and development meetings at regular intervals through the year. Fuller documentation has been obtained from the visiting hairdresser relating to her public liability insurance and clearances to work with vulnerable adults. She is now issuing individual receipts to each resident to acknowledge payment for hairdressing services. St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 7 Records at the home continue to improve in a number of areas, for example there are records on file to show that all residents have regular multidisciplinary reviews and these are now signed by the resident or their representative. The manager has taken action to make sure the damaged bedside table in a residents bedroom noted at the last inspection visit has been replaced to remove the risk of injury. Additionally all residents have been provided with new bedside tables with lockable facilities and new sets of colour-coded bedding have been purchased. The entire interior of the home is being redecorated. The work started on 28 November 2005 and should be completed within eight to ten weeks. Residents are able to choose the colour scheme for their own bedrooms. The home has managed the finances well and has contingency funds in hand, which may mean that some future improvements may be brought forward. A new larger shed has already been provided and the trees in the rear garden have been pruned. Consideration is being given to the creation of a hairdressing room, the installation of a new call system and new patio furniture. The systems of safe working in the kitchen and safe use of catering equipment have been looked at again to see if more improvements can be made. 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 Marks House DS0000025028.V269854.R01.S.doc Version 5.0 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 St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards have been assessed at the inspection visit on 21 June 2005 and are satisfactory. The home has no vacancies and there have not been any new residents admitted since the last inspection visit. EVIDENCE: St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 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): 6,8 There is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet residents needs. EVIDENCE: There is evidence that all residents have a care plan in place. During discussions with residents during this visit they have confirmed that there is active involvement in developing and implementing their own care plan. This reflects their preferred lifestyle and routines, such as spending time alone or going out unaccompanied. The home continues to have a comprehensive risk assessment system in place for each person. The documented risk assessments are colour-coded for each area of risk. Examples are the risks of living on the first floor (Green), going out unaccompanied (gold), self-medication (pink), smoking (yellow). The residents daily notes assessed now contain fuller details of the care offered, however further expansion is required to reflect how goals and care needs identified in the care plan are evaluated.
St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 11 Residents take an active role in the running of the home. Each person is provided with a key worker handbook giving detailed information about what they can expect from the staff. The residents are regularly consulted about all aspects of their lives through care planning reviews, formal reviews, residents meetings and surveys. The home has good documentary evidences of the outcomes and decisions agreed with residents. St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 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): 14,15,16 Residents are supported to take advantage of leisure activities, including an annual holiday. Links with families, friends and the local community are good, enriching residents opportunities for social stimulation. EVIDENCE: The majority of residents were at home at some times during this inspection visit. One person left the home early during the visit to go shopping. She comments that she enjoys going out unaccompanied and using public transport. Other residents have been observed making their own drinks and taking responsibility for household tasks, some with support from staff. The annual holiday took place at Sand Bay this year in the week following the previous inspection visit. The holiday as usual has been funded from the budget at St Marks and CHADD and was greatly enjoyed the group of residents who participated. The home has a structured activities programme, discussed with the residents and generally organised and led by members of staff. Stimulating and challenging board games and quizzes are among favourites. In discussions
St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 13 with staff they demonstrate awareness that some people prefer not to participate in structured activities but may need support with individual leisure pursuits. There are records of discussions about a canal boat trip in the minutes of residents meetings. This was obviously a successful outing. There is a visiting policy, which is displayed in the home. Visitors can be received in private in residents’ bedrooms and in the quiet areas of the home. Discussions with the residents and examination of a sample of records indicate that every effort is made to promote positive relationships with family members, friendships in the wider community and where appropriate within the home. Each person has a varying amount of contact with family and friends, with details of any additional support recorded in case files. Each person has details of advocacy services available in the key worker handbook and there is signed evidence of receipt of this document on each persons file. St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 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): 19,20,21 The health needs of residents are well met with generally good evidence of multi disciplinary working taking place on a regular basis. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure residents medication needs are met. EVIDENCE: The residents continue to be encouraged and assisted to attend health care screening programmes such as well person checks. Each person has their preferred option of dentist, optician and chiropody service. There is evidence that staff are allocated to work extra hours to their usual care rota, to act as escorts for residents to attend appointments. One of the older residents has been identified as being at risk of poor nutrition and whilst there is evidence of a referral to the community dietician there is no documented nutritional screening tool and tissue viability assessment and the home is no longer using food charts to record food and fluid intake. The home has comprehensive medication policies and procedures and all staff administering medication have received accredited medication training. The home uses a monitored dosage system MDS and half of the residents administer their own medication, with support and agreed monitoring.
St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 15 A number of small improvements have been introduced as a result of advice given at the previous visit. There is now a specimen signature list of all staff involved in the administration of medication, held with the MAR sheets and a copy of the homes medication policy / procedure is held with the medication system, with staff signatures, demonstrating their awareness and compliance. The home has obtained a more up-to-date BNF, however this is now more than 12 months old. Additional minor areas of the medication system need improvement as a result of assessment at this visit. Examples are that staff must ensure that handwritten MAR sheets contain the same level of detail as pre-printed sheets, such as dose, form, route, time; and handwritten entries or changes on MAR sheets are currently not signed and witnessed by two staff. The home has a policy, procedure and guidance for staff relating to dying and death, however these need to be reviewed and expanded especially relating to cultural customs for faiths other than Christian or Jewish. The person who is Muslim may wish to observe particular practices during the processes of dying and death. There are currently no final wishes recorded for this older resident. St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 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): 22,23 The home has a satisfactory complaints system with evidence that residents feel that their views are listened to and acted upon. Policies, procedures, guidance and staff training have been implemented in order to provide residents with more safeguards from abuse. EVIDENCE: The home has a satisfactory complaints procedure, which is displayed in the reception and is contained in the service users guide and key worker hand book, given to each resident. There have been no complaints recorded in the home’s complaints log since the last inspection visit in June 2005. Residents feel that they can voice any concerns either through their meetings or directly with the manager or staff at the home. The home has a copy of the local authority multidisciplinary procedure for the protection of vulnerable adults: Safeguard & Protect. Although the manager feels staff are aware of adult protection processes there is currently no documentary evidence that all staff have read and have an awareness of policies to protect vulnerable adults. The home has improved the protection of residents finances as a result of discussions at the last inspection visit and now has individual receipts from the hairdresser for each financial transaction with individual residents and there are copies of the hairdressers public liability insurance cover and evidence of a satisfactory POVA / CRB clearance on file. St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 17 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): These standards have been assessed at the inspection visit on 21 June 2005 and are satisfactory. The standard of the décor within this home is very good with evidence of improvement through maintenance and future planning. The home presents as a homely and comfortable environment for residents. EVIDENCE: St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 18 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,34 Staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. The rigorous recruitment processes provide safeguard for the residents living at this home. EVIDENCE: The majority of these standards have been assessed at the inspection visit on 21 June 2005 and are satisfactory. Discussions with staff indicate that they have a good understanding of their job role and of the needs and rights of residents. Good progress is continuing to provide staff with appropriate levels of training. There is a structured supervision system, with appropriate topics to support and develop each member of care staff. There is warm and empathetic rapport between the residents and staff. Residents are looking forward to events with the staff to celebrate Christmas and there is a good deal of banter taking account of residents abilities and sensitivities. People are complimentary about the staff, their helpfulness and thoughtfulness. There are records for all staff working at the home, however these have not been assessed in depth at this visit. There is sufficient documentary evidence that improvements needed at the last visit have been put in place. There are
St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 19 now copies of interview questions and answers retained on personnel files, though these would benefit from being more specific, signed and dated by the interviewers. St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,40,41,42 The management of the home provides clear leadership and communication systems are generally very effective and staff are clear about their roles and responsibilities. There are generally effective systems in place to seek the views of residents and relatives views of the homes performance. The standard of records at this home continues to improve, which provides residents with better safeguards. EVIDENCE: St Marks has good arrangements in place to ensure that residents are consulted about the day-to-day running of the home. There are regular and recorded residents meetings, with a wide range of topics discussed about the running of the home and future plans. There are regular residents feedback questionnaires, which are collated and published. The home needs to consider ways to formally seek the views of wider stakeholders as to the performance and how well residents goals are achieved. St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 21 The home has yet to implement an externally accredited quality assurance system, although it continues to hold accredited Investors in People Award. There is evidence of an annual development plan, which reflects recent improvements, actions for the current year and plans for expenditure and staff development for the forthcoming year. Examples are planned staff training relating to drug administration, emergency first aid, continence management, health & safety and distance learning for infection control. In addition there are a number of monitoring arrangements in place including unannounced monthly visits from the committee members, with reports, which are given to the home and copied to the CSCI. The home has policies and procedures, which are readily available for staff guidance. The manager and staff are in the process of reviewing various policies and procedures, though there are some still needing to be updated such as policies relating to dying and death. There is good evidence that staff are continuing efforts to improve the standard of record keeping. The manager has taken action to minimise the risk of injury by replacing the damaged bedside table in BPs bedroom; and ensuring that risk assessments dated 29/10/02 for the kitchen and catering equipment have been reviewed and updated and that a risk assessment for the deep fat fryer has been devised and implemented. Contact has been made with Dudley MBC Environmental Services to seek their view of the training risk management provided from the training provider, without accreditation, however no formal response has been received to date. There are 9 recorded accidents involving residents and 1 involving a member of staff, since the inspection visit in June 2005, with evidence that a regular accident analysis takes place. St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 X X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X 3 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
St Marks House Score X 3 2 2 Standard No 37 38 39 40 41 42 43 Score X X 2 2 3 2 X DS0000025028.V269854.R01.S.doc Version 5.0 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA19 YA19 Regulation 17(2) 13(1)(4) Timescale for action To resume food charts for NJ and 01/02/06 any other resident at risk of poor nutrition or poor appetite To undertake appropriate age 01/02/06 related health screening assessments for any older residents potentially at risk, such as a documented nutrition screening tool and tissue viability assessment 1) To clarify as directed 01/02/06 dosages with the prescriber and/or the pharmacist (Timescale of 31/07/05 Not Fully Met) 2) To ensure that there is an upto-date BNF, that is no more than 12 months old (Timescale of 31/07/05 Not Fully Met) 3) To ensure that handwritten MAR sheets contain the same level of detail as pre-printed sheets, such as dose, form, route, time 4) To ensure handwritten entries or changes on MAR sheets are signed and witnessed by two
St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 24 Requirement 3 YA20 13 (2) staff 4 YA21 15(1) 17(1) 1) To review and expand the homes policy, procedure and guidance for staff relating to dying and death, especially cultural customs 2) To continue sensitive discussions with residents / and / or their representatives to record any final wishes 1) To rectify the small amounts of staining and corrosion around the base of the WC in the en suite in FCs bedroom 01/03/06 5 YA26 23(2) 01/02/06 6 YA42 13(4) 2) To undertake minor renovation and redecoration to the damaged paintwork on the en suite door in NJs bedroom To contact Environmental 01/02/06 Services to seek their view of the training risk management provided from the training provider, without accreditation, taking action in accordance with advice (Timescale of 31/07/06 Not Fully Met) 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 YA23 YA39 Good Practice Recommendations That staff signatures be obtained to provide evidence that all staff have read and have an awareness of policies to protect vulnerable adults That consideration should be given to ways to formally seek the views of wider stakeholders as to the performance and how well residents goals are achieved St Marks House DS0000025028.V269854.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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