CARE HOME ADULTS 18-65
St Michaels 166 London Road Temple Ewell Dover Kent CT16 3DE Lead Inspector
Julie Sumner Key Unannounced Inspection 17th January 2007 10:00 St Michaels DS0000023580.V307187.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 Michaels DS0000023580.V307187.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 Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Michaels Address 166 London Road Temple Ewell Dover Kent CT16 3DE 01304 823017 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) High Quality Lifestyles Limited Mr Duncan Robert Wood Care Home 7 Category(ies) of Learning disability (7) registration, with number of places St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th March 2006 Brief Description of the Service: St Michaels is a home for people with learning disabilities and communication difficulties who present challenging behaviour at times. The home is owned by a private company: High Quality Lifestyles. The companys philosophy is to support people who have displayed behaviour that has caused them and others difficulty and has limited ordinary/usual kinds of life opportunities by positive guidance and a specialised environment. The current fees for the service at the time of the visit range from £1885.00 to £3110.00. Information on the home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address for the home is stmichaels@hqls.org.uk. St Michaels is registered to provide accommodation for up to 7 people. It is the companys intention for a maximum of 5 people to live in the home in order to provide a high quality level of support to each individual. At present 3 people live in the home. St Michaels is a detached home in the village of Temple Ewell near to the town of Dover. There are basic amenities within walking distance of the home and the town of Dover is approximately 15 minutes drive. There are reasonable public transport links near to the house and there is the facility for service users and staff to use the house car. St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a key inspection and short notice was given to make sure the inspection process did not inhibit the service provided to service users. St. Michaels provides a structured, responsive service to service users. The inspector visited the home to talk to service users and staff and view records and practices. The time spent in the home overall was just around 7 hours. Information was gathered for this inspection by a variety of means both prior to and during the visits to the home. The CSCI request information from the home routinely and the manager provided all the information requested in the pre-inspection questionnaire prior to the inspection visit. Feedback questionnaires were sent out some time before the inspection visit and there was a positive response. There is a current adult protection investigation open following an incident in the home that happened in October 2006. 8 requirements have been made as a result of this inspection, 3 requirements have been carried over from the previous inspection. What the service does well: What has improved since the last inspection?
Two service users now have a different kind of written support plan that is designed with their involvement. One service user designed his own on the computer. The plans are colourful, have pictures, printed photos, symbols and clear writing to describe what is important to each individual, what they like to do, what they do not like, how they like to be supported, what they want in the future and how they plan to achieve it. This is a more meaningful way of St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 6 demonstrating each person’s preference in how they wish to be supported with their chosen lifestyle. It is only recently that the staff team has been increased and until then it would not have been possible to carry out the service user plans fully for each individual. Staff were very positive about having sufficient staff to go out with service users more often and are now able to carry out service user plans fully. A new training coordinator has been employed and has provided an increase in training available. Nearly all staff have attended essential training and training required by law or refresher courses are booked. The requirement, from the previous two inspections, to increase the available training courses has been met. What they could do better:
In the last inspection there was evidence of good practice with regard to supporting service users with their behaviour and challenging their energy into positive occupation. Following an incident an adult protection alert was raised. The recent adult protection investigation has questioned whether this is consistent throughout the service. The following shortfalls were highlighted as result: insufficient knowledge in how to report an incident, lack of security of documentation, lack of confidence and understanding of the adult protection procedures and not being able to determine when it is necessary to seek medical/professional advice. In this inspection there was some evidence of good practice and competency. Staff spoken to were experienced and knowledgeable about adult protection protocols and confident in when to manage a situation and when to seek assistance. Some work needs to be carried out by the registered manager to reassess the skills of the staff team overall to check competency throughout and give further supervision and training if shortfalls are identified. A requirement has been made for this and also to make sure staff are trained sufficiently in first aid. The home is in a poor state of repair. The roof was leaking on the day of the visit. An urgent requirement was made for this. The home looked shabby in areas, there were several areas where repairs and redecoration was needed and furniture was worn out. Improvements need to made to the building and utilities to make it a safe place to live and work in. A requirement has been carried over to provide a written maintenance and refurbishment plan to address these shortfalls. The manager needs to make sure new staff are supervised sufficiently whilst recruitment safety checks are being processed. No staff should start work without a POVA check first. A requirement has been made for this. There is a need to develop a quality assurance system to make sure that how the home is supporting service users and what is happening in the home is
St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 7 fully meeting everyone’s needs and wishes. The requirement made at the previous inspection has been carried over. The building work to improve the access to the home by providing an alternative entrance is underway. This is being built to incorporate the fire safety officer’s recommendations and will allow staff and visitors to be briefed and to enable informed positive responses when first meeting with service users. The requirement made at previous inspections has been carried over as it is necessary to incorporate it into the building work and has therefore delayed the erection of the perimeter fence (proposed in the fire safety recommendations). 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 Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments are comprehensive and form a good basis of the service user plan. EVIDENCE: There have been no new service users. A sample of assessment information was viewed. A community nurse has recently reviewed one service user. St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know that their views are taken into account and that their personal goals are reflected in their individual plans. Risk assessments need to be expanded to incorporate clear guidelines for staff when managing distressed and aggressive behaviour. EVIDENCE: A sample of service user plans and daily logs were viewed. There were clear behaviour guidelines in place. Staff were observed to respond to service users in line with guidelines on the day of the visit. The service user plan format is being reviewed and staff said they did not really find them easy to refer to. Experienced staff know the guidelines well enough to only refer to the plans if there are changes. New staff said they did refer to the guidelines. Two person centred plans have been designed. One service user compiled his own mostly independently using his computer. They include who and what is important, likes and dislikes, future goals and action plans to achieve them. Both are set out differently.
St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 11 The service provided in the home was observed to be service user lead, staff were observed responding to service users’ wishes and directing them to constructive occupation. Risk assessments define necessary restrictions and interventions that have been agreed by funding representatives. These have been reviewed 6 monthly. There are guidelines for behaviour interventions and the risks need to be highlighted to increase staff awareness. St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 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): 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. Leisure activities offered are flexible and responsive to individual needs and wishes. Routines in the home are flexible and freedom is promoted within risk assessed boundaries. Service users’ families are supported to be involved with their lifestyle as much as they wish. Service users are provided with a good range of meals and are able to choose where and when they want to eat. EVIDENCE: Service users participated in a variety of activities during the day of the inspection visit including going out into town shopping, going for a walk, having a sensory session and going to the local shop. Individual activities
St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 13 plans were viewed that are used as a basis for what is offered. One service user goes to college. All service users have computers. Service users require the support of two staff when in the community. The rota indicated 4 staff on each shift, which restricted service users going out on a turn taking basis. Staff said that this made responding to their wishes difficult if someone was already out and had sometimes exacerbated challenging behaviour. In response to the adult protection investigation an additional member of staff is on duty during the day. Staff said this has made a significant difference. Service users were observed to be active throughout the day. There were references and documentation that indicated that service users families are important and service users keep in contact with the support of staff. There are no set times for meals as mealtimes are dependent on what activities service users are participating in. Service users do not always sit together and individual wishes are respected. Lunch on the day of the visit was informal and sociable. St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 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, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff would benefit from further training to support individuals with their health care. The systems for medication administration are good with clear and comprehensive arrangements being in place to ensure service users medication needs are met. EVIDENCE: Service users have indicated in their person centred plan how they like to be supported. Observation of interaction showed that staff were responsive to service users and listened to what they want or responded to non-verbal communication. All service users are registered with a GP and go down to the surgery for arranged appointments with support of staff. There is a record of all appointments attended. There are health check update sheets, which are completed for every incident related to individual health and kept in their service user plan folder for reference. A sample of health records were viewed and discussed.
St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 15 Following a recent event staff were unclear about how to respond to an individual’s health need and a medical assessment that should have been made earlier was delayed. All staff have attended a first aid one day course and the manager and one senior member of staff have attended the first aid at work, 4 day training. The manager said that this course was more relevant to the needs of service users as it deals with everyday general first aid cuts and bruises etc. The proportion of staff with the approved first aid training, need to be reviewed to make sure there are sufficient staff on duty with this training at all times. A requirement has been made to make sure that the correct ratio of staff are on duty with approved first aid training. Medication records, storage and guidelines were viewed and discussed with the manager. St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is an effective complaints procedure for relatives and advocates and a modified version for gaining service users’ wishes and feelings. The policies and procedures in the home have been insufficient to protect service users at all times. EVIDENCE: There is a complaints procedure and this is included in the statement of purpose/service user guide. Staff get to know service users and judge from their responses and behaviour if they are unhappy about something. The registered manager has one-to-one meetings with one service user who continues to benefit from having this time to talk through any concerns. The complaints procedure also needs to extend to service users who have communication difficulties. There is a complaints log and there have been no complaints. Risk assessments have been designed to support individuals and minimise risk of harm. Staff have received training in diverting negative behaviours and management of aggression. Staff have attended adult protection training. However, an incident in the home has prompted an adult protection investigation and through this it has highlighted some inadequacies in the reporting process. A requirement has been made to make sure that all staff understand how to put the adult protection and whistle blowing procedures into action. This should clearly state what, when and to whom an incident or anything that is related must be reported. A requirement has also been made
St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 17 to routinely monitor and assess competency with physical restraint and make sure the guidelines for each individual are clear and protect both the service users and staff. The company adult protection policy and whistle blowing procedure are in the process of being revised. St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 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, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Not all parts of the home are homely and comfortable. Areas in the home are in serious need of repair or replacement. The state of the décor has compromised the cleanliness of the home. EVIDENCE: A tour of the home was carried out with a member of staff. The new access and refurbishment at the front of the house was underway with workmen on site. The area was sectioned off to prevent access by service users. Some internal decorating was being carried out at the same time. Overall, the home was not in a very good state of repair. There were several areas of water damage in the ceiling and down walls where the roof had been leaking. The settees and arm chairs were very worn. The building and furniture does suffer from considerable wear and tear due to some destructive challenging behaviour and there is a programme of replacement and repair but this needs to be reviewed to make sure it is timely to accommodate this. A
St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 19 requirement has been made to repair the roof urgently and to provide a written plan of refurbishment and replacement to maintain the home. Service users rooms have been personalised and are designed to accommodate their needs and preferences. The lounge was decorated, has new furniture and was clean. From discussions and observation service users seldom use this room. The living room in the centre of the first floor called the games room is used more frequently. It was clean and had good light. The furniture in this room was worn. There is another sitting room which is preferred by one service user and this was also furnished some of which had been adapted to accommodate destructive behaviour. Seating in this room was also worn. The bathroom was clean. It showed signs of destructive behaviour and there was some water damage. The laundry had puddles on the floor and there were buckets to collect the water running from the leaks in the roof. Washing machines were working. Staff have attended infection control training. St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 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): 32, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The absence of POVA check prior to new staff starting work may put service users at risk. A review of supervision of new staff whilst waiting for CRB clearance will help protect service users and new staff. The home is currently staff sufficiently and this staffing level needs to continue to meet individual needs to meet individual needs. There is a good range of training to meet individual needs. Further support and monitoring would benefit staff to make sure that training is put into good practice. EVIDENCE: A sample of staff files were viewed. The focus was on checking the recruitment process for the most recently recruited staff. The files were well organised with evidence of references being taken and an interview procedure. CRBs had been requested for all staff. It is the company’s policy to directly supervise and shadow new staff until the CRB disclosure has been returned. Due to the nature of the work it is not always possible to supervise new staff at all times. Service users have requested to be supported with an activity with different staff and this may include requests to work with new staff. It
St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 21 was observed that sometimes new staff worked with individuals with activities one-to-one and were not directly supervised. The POVA check is requested as part of the CRB application but there was insufficient evidence that there had been confirmation that the POVA check had been completed prior to new staff starting work. Discussion with a member of the company HR staff a few days after the inspection visit confirmed that the POVA request was made and that two out of three new staff had CRB disclosures returned but not prior to them starting work. A requirement has been made to make sure there has been POVA clearance prior to new staff working in the home and to review the effectiveness of the shadowing procedure whilst staff are waiting for CRB clearance. One of the new staff discussed their induction training and some of the content of the training was viewed. They were very positive about the training they had received so far and said they were already feeling confident in the home. The company have reviewed the training provided again and there has been an increase in training provided. This has enabled the manager to ensure that staff have up to date mandatory training and there were only minimal gaps in staff updates or new staff booked to attend training. NVQ training has progressed. The experienced staff who were spoken to during the visit had all completed NVQ training either level 2 or 3. New staff are booked onto the NVQ level 2 course when the induction training is complete. A new member of staff spoken to was booked on the next course. New staff have had induction training and they spoke positively about their experience of working in the home. St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 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, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a clear vision. The manager would benefit from additional support to make sure the home is fulfilling its statement of purpose. Development of the quality assurance monitoring system would determine whether the service being provided in the home is what service users want and is meeting their needs. This would provide the basis for the development plan for the home. Improvements need to made to the building to make it a safe place to live and work in. EVIDENCE: The registered manager has over two years experience in management and has completed NVQ 4 in management and care. HQL has designed a training programme for the senior staff to provide them with specialist skills to support
St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 23 people who display challenging behaviour. The registered manager is currently studying the second year of this course. There was evidence that despite requests to make improvements to the home and what is provided this has not been responded to. Work on the environment has been slow despite the dire state of areas of the building especially the roof which was leaking badly on the day of the visit. The increase in staff has been in response to the adult protection alert. Although the need had previously been identified by the manager. Training provision has also only recently been increased although this has improved greatly since the last inspection. The company has not developed the quality assurance system yet although management staff have recently been employed to design and implement this. Environmental risk assessments have been carried out by the manager and identify areas of need as referred to in previous paragraph. The necessary routine servicing of heating, water, gas and electrical services have been carried out with no routine requirements. However, there have been recent problems with the heating and there was a time during November when the heating had broken down. The repair or replacement of equipment and the systems in the home need to be included on the maintenance and refurbishment plan for the home. Building is underway for the new access which will incorporate fire safety recommendations. St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 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 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 2 ENVIRONMENT Standard No Score 24 1 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 x 2 x x 2 x St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes 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 YA19 Regulation 13(4) Requirement Make sure that there are sufficient staff on duty with approved first aid training in line with HSE ratios of staff to service users and having assessed the needs of the service. Timescale for action 31/03/07 2. YA23 13(6) 21(1-2) All staff must understand 31/03/07 how to put the adult protection and whistle blowing procedures into action. This should include and clearly state what, when and to whom an incident or anything that is related must be reported. Routinely monitor and assess staff competency with physical restraint and make sure the guidelines for each individual are clear and protect both the service users and staff. The leaking roof needs repairing. 31/03/07 3. YA23 13(7) 4. YA24 23(2)(b) 14/02/07 St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 26 5. YA24 23(2)(b) There needs to be a written maintenance plan to include all necessary repairs and refurbishment to the home with timescales. A copy of which should be given to the commission by timescale. Make sure there has been POVA clearance prior to new staff working in the home and to review the effectiveness of the shadowing procedure whilst staff are waiting for CRB clearance 31/03/07 6. YA34 12(1)(a-b) 18(2)(a) 14/02/07 7. YA39 24(1)(a,b)(2)(3) To set up a quality assurance audit system within the company to measure success in achieving aims and statement of purpose of the home based on views of service users and their representatives. System structure and planned implementation to be completed by timescale. (previous timescale March 2006, 31/05/06 not met.) 12(1)(a,b) 23(4)(b) Implement fire safety guidance recommendations and ensure safety of service users when evacuating the building in the event of fire.(previous timescale 31/05/06 not met due to delays in building work which is now underway) 31/03/07 8. YA42 30/04/07 St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations There are guidelines for behaviour interventions and as part of these the risks need to be highlighted to increase staff awareness. To extend the maintenance and renewal plan to replacement of furniture and equipment to speed up the time it takes to acquire the items requested/needed. To continue to work towards achieving NVQ targets. 2. YA24 3. YA32 St Michaels DS0000023580.V307187.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Kent and Medway Area Office The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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