Inspection on 18/11/05 for St Patrick`s House

This inspection was carried out on 18th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Patrick`s House 07/02/08

St Patrick`s House 16/11/06

St Patrick`s House 13/06/05

St Patrick`s House 04/02/05

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 St Patrick`s House Porton Road Amesbury Wiltshire SP4 7LL Lead Inspector Mrs Jacqui Burvill Unannounced Inspection 18th November 2005 09:30 St Patrick`s House DS0000060340.V266224.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 Patrick`s House DS0000060340.V266224.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 Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Patrick`s House Address Porton Road Amesbury Wiltshire SP4 7LL 01980 626434 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) Cornerstones (UK) Ltd John Edwin Maloret Care Home 8 Category(ies) of Learning disability (8), Physical disability (1) registration, with number of places St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only the one, named, male service user currently in residence in the age range 18 - 64 years with a physical disability may be accommodated in the home. Any placement for short-term care must be agreed with the Commission before placement commences. For the purpose of this condition, short term is defined as a placement that will not last longer than three months. Any placement that will last longer than three months must be reviewed to assess the short-term status of the service user. Any placement of an emergency admission must be notified to Commission in advance where possible, or within the next working day, or two days if over a weekend. An emergency admission is defined as an admission where a service user is likely to be placed at short notice without an up to date assessment of needs having been carried out and the person has not had the opportunity to visit the home prior to placement. 13th June 2005 2. 3. Date of last inspection Brief Description of the Service: St Patrick’s House is an 8 bedded home for adults with learning disabilities aged 18 - 65 years. Both male and female service users may be admitted. The home provides a service to people who may require high level support with behavioural problems, communication difficulties and psychological problems. The home does not provide care for people requiring high levels of support for personal care needs. The home is one of 6 homes owned by Cornerstones UK Ltd, a company run by Mr and Mrs Sinclair. One of the other homes is adjacent to St Patrick’s. St Patricks is a large chalet bungalow with a large garden to the rear of the property and space at the front for several vehicles. It is within walking distance of Amesbury town centre and local amenities. The home was first registered on 31st January 2003. At least four staff are on duty during the day time and two staff sleep in at night. St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 18th November for six and a half hours. Five staff were spoken to, including the deputy manager. The manager was also present during part of the inspection. Five service users were met with. Service users spoke about their lives in the home, the activities they enjoyed taking part in and three service users showed the inspector their bedrooms. The following documents were looked at: complaints and compliments, medication, care plans and risk assessments, assessments and admission records and menu plans. There was a tour of the premises. The home was extended during the summer and the registration was changed from 6 to 8 beds. The extension included two bedrooms with full ensuite bathrooms on the ground floor, with a staff training and meeting room, a staff sleep in room and a bathroom on the first floor. There is space on the ground floor for an area that can be used for games or recreation. The most recent registration certificate was not in place. This was sent to the Cornerstones UK Ltd office and must be displayed in the home, as it is an offence not to display the registration certificate. There is one vacancy. What the service does well: Service users have a range of activities on offer in the local community. Although not all service users take part, each service user has an activity plan devised every week, this includes social and recreational activities they like to take part in. Staff support the service users when out in the community. Staff have been supporting service users in medication changes. Instructions were clearly written for staff to follow. St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 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 Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 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): 2 The admission process was not followed in the most recent admission. This may lead to service user’s needs not being fully assessed to ensure that the home could meet their needs prior to admission. EVIDENCE: The deputy manager informed the inspector that the Statement of Purpose and the Service users Guide were under review as they are going to be updated. Copies will need to be sent to the CSCI when completed. The new service user has signed a contract about acceptable behaviour in the home and this has also been dated. It is not clear what would happen if the terms of this agreement were broken in any way. There is no contract in the file between the social services department and the organisation. There are documents relating to the previous placement and an introduction to the support plan gives background information about the service user’s past history. No assessment was completed prior to admission. The home has a condition, which allows an emergency admission, but documents are to be passed to the CSCI prior to admission where possible. The inspector was aware of the urgency of the admission, but did not receive any documentation about the service user. The service user in question was well known to the manager, who had unusually, been supporting staff in the previous placement with the management of behaviour. The admission was made because of a crisis in the previous placement. Because the service user was known to the manager, it St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 9 appears as though the admission process was not followed, as no assessment of the service user’s needs or how they would fit in with the other service users was made, or recorded. An assessment of the service user’s skills is currently being worked through. The service user was asked about the admission process. There were some single visits made as part of an introductory process and this information was supplied following the inspection. The service user said he had a new bedroom and appeared to like this. St Patrick`s House DS0000060340.V266224.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, 7, 9 Standards 6, 7 and 9 were assessed as met at the last inspection. Service users have up to date care plans that enable staff to support them. EVIDENCE: Two service users’ care plans were looked at. This included the care plan for one new service user. The organisation is planning to introduce a new care plan format. This was in place for one service user and was well detailed, with clear concise information on how the plan was aimed at meeting the service user’s needs. The other care plan was not in place in the service user’s file, but was found to be up to date on the home’s computer system. The care plan was not in the new format, as this will be phased in gradually. However, it was up to date and relevant to the service user’s needs. The new plan is not led by the service user, but is structured in a way to support service users with their known behaviours that may prevent them from having a valued and fulfilled life. Care plans are evaluated monthly, where staff identify any trends in behaviour, emotional health of the service user as well as any physical health issues. St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 17 Standards 12 and 15 were assessed as met at the last inspection. Service users benefit from a range of activities on offer and from staff who support them. Service users enjoy the range of food available in the home. A lack of detailed recording lets down the choices available to service users. EVIDENCE: The majority of service users take part in community education or recreation. The variety of activities includes day care centres and local college in Salisbury. Each service user has a weekly chart that details all of their activities. This includes any work related options they may have. The record includes service users meetings and evening activities such as skittles. One service user described the activities he was taking part in and clearly enjoyed this and appeared to benefit from the experience. Staff explained that they supported some of the service users during their activities in the community, staying with them during the sessions. St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 12 Another service user spoke about the part time job he had and the activity he was about to take part in that day with a member of his family. Not all service users have full programmes of activities, but their own chart describes what activities they can take part in, in the home. Menu records detail some of the meals that have been provided, but they are not recorded in sufficient detail or consistent. A service user prepared his breakfast during the inspection and the record later showed that not all of the meal that was cooked had been recorded. Some entries for lunch and main meals had been left blank. On occasion when service users eat out codes are used to record this. St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Standard 18 and 19 were met at the last inspection. Some recording errors in medication may put service users at risk. EVIDENCE: All staff are completing medication training at this time. Seven staff have completed the course and the remainder of the team need to have their competence assessed by the manager or deputy manager. There are guidelines in place for the weekly medication checks that staff do. This records any medication that has been lost or destroyed. Staff recorded that on two occasions, they ‘popped’ tablets accidentally from the blister pack. The reasons why staff may have done this was discussed with the deputy manager. There was very clear guidance on medication reductions and changes, which were complex. A guide had been written for staff to follow and the MAR sheet had been fully prepared to manage this change and referred to accompanying letters from healthcare professionals. Staff have had to handwrite entries onto the medication sheet on some occasions and two staff had not witnessed the medication and the instruction. The inspector noted that medication given the night before had not been signed and pointed this out to the deputy manager. St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 14 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 Service users do not benefit from a robust and accessible complaints procedure. This may lead to them feeling their views are not listened to or acted on. Service users are not fully protected by staff training and awareness in adult protection. EVIDENCE: There is a complaints procedure in the home. There has been one complaint recorded since the last inspection. This is recorded in a duplicate book, so the service user can receive a copy of the complaint and any action taken. On this occasion, the deputy manager said the service user did not want a copy. During the inspection, the inspector was made aware of a recent complaint, made by a service user about another service user. This had resulted in service users changing bedrooms. The complaint had been resolved to all of the service users’ satisfaction, but this example of good practice had not been recorded. Through the reporting of other incidents under regulation 37 notifications, service users who had been affected by the behaviour of another service user did not appear to have been offered the complaints procedure. This was discussed at length with the manager during the inspection. The CSCI does not need to be informed of complaints, but the complaints procedure must be robust and accessible to service users. The manager feared that there might be too many complaints recorded. Some judgement will need to be exercised in order to ensure that when the complaint affects the well being of service users that the complaint is recorded and responded to and that action is taken to try and resolve the complaint. Where this is not possible, the record should show what action has been taken as a consequence. St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 15 It may be advisable for the home to contact the care managers to identify what level of complaint should be recorded. Staff have not received any specific training in adult protection. The deputy manager has, and will be devising a course that will be cascaded, so all staff can be trained. Two staff have received this training, but only one works at the home now. Currently, other staff may only have received this as part of LDAF induction training. This has been a requirement due to be completed by 31st July 2005. The deputy manager said that she would train the staff by the middle of December. Some of the regulation 37 notifications have been about service users’ well being. One incident was reported through the Vulnerable Adult Procedure during the inspection. The manager strongly disagreed with this referral and felt that it was not necessary. There was a subsequent early strategy meeting, when it was decided that the service users’ safety had been compromised and that referrals to psychologists might help further develop the behaviour management strategies in the home. Staff reporting regulation 37 notifications must ensure that the information is clear and objective. One regulation 37 notification could have been interpreted in two different ways. Another showed that staff had apparently lied to a service user during an incident. The inspector was later informed that staff had forgotten to include the full details they needed to record which may have shed a different light on the matter. St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The accommodation meets the needs of the service users. Service users would benefit from more attention to the quality of the decoration and finishing touches to the home. EVIDENCE: The home was extended during the summer and this extension includes two service users bedrooms, one with a shower room, toilet and hand wash basin and the other with a bath, toilet and hand wash basin. The rooms are in excess of 12 square metres and are well appointed. They have been poorly decorated, which lets down the quality of the accommodation. There is a communal area, which was used as a games area for a snooker table in the afternoon. This was to be a computer area, but the computer is stored under the main stairwell, along with other items. These other items must be removed, as they are a fire hazard. The manager must ask the fire officer if the computer can be stored under the stairs when it is off. Service users were happy with their rooms and three service users invited the inspector to see their rooms. One bedroom has a large window opening onto the front driveway. There are full length curtains, but there are privacy and dignity issues and some kind of opaque screening or curtains should be provided. St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 17 There is a new utility room in the extension. This was to replace the existing utility room close to the dining area in the kitchen. Both utility rooms are now going to be used as the new one is too small to deal with the demands of a full house. The home was clean and tidy on the day of inspection. There are some areas of the home that need to be addressed as maintenance issues. One includes a shower base that is lifting away from the side of the shower. Lampshades need to be purchased and curtains for the unused room. Staff are currently using this room as one of the two sleep in rooms. The other room is on the first floor. When a service user occupies this room, the second office on the ground floor will need another bed, as this will also be a sleep in room. The large communal sitting room has more furniture and pictures and has a homely feel. There is a large dining table in the kitchen and it was pleasing to see some service users clearly at home on arrival after being at college or day care, making themselves drinks and snacks. There are plans to alter one of the ensuites so as it can be made into a walk in shower room suitable for someone with a physical disability. The manager should obtain guidance on appropriate equipment from an occupational therapist. The rear garden has been levelled and laid to lawn. More may be made of this space next year. St Patrick`s House DS0000060340.V266224.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): 34 The recruitment practice partly protects service users’ safety. Standard 35 was assessed as partly met at the last inspection. EVIDENCE: The recruitment records were looked at. All new staff have a CRB certificate and a POVA First where this was needed. Where there are positive results on the CRB certificates, the registered manager must ensure that there is a process in place to check that the potential employee has been asked about these offences and that a risk assessment has taken place. The application forms in place have been amended and in doing so, the section asking staff about any past convictions has been omitted. This was discussed with the deputy manager, who plans to replace this. There is a candidates checklist to record all of the information received, but this has not been used in all cases. New employees have two references. New staff have also signed to say that they have received copies of the General Social Care Council code of conduct and the Wiltshire and Swindon ‘No Secrets’ guide. St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 19 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, 42 A lack of overseeing on delegated managerial tasks may mean that service user do not benefit from a well run home. Standard 39 was assessed at the last inspection but not met. Work is continuing on monitoring quality assurance systems in the home. The lack of regular fire safety alarm checks and an up to date fire risk assessment could put service users’ safety at risk. EVIDENCE: The manager has been in place since the home was opened. He has a range of skills in managing service users with challenging behaviour. He has overall responsibility, although some tasks are delegated to the deputy manager and other staff in the home. The manager is responsible for ensuring that certificates are in place. The registration certificate, which was sent to the Cornerstones UK Ltd office is not on display and the certificate that is on display is out of date. St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 20 The fire safety records were looked at. During a period of two weeks in November the nominated fire person had been on leave. The responsibility for these duties had passed onto another team member, but no records had been made to show that the fire alarm systems had been checked weekly. The nominated fire person then set off the alarms whilst the inspector was present. Service users were informed that this would take place and one service user told the inspector that this is what happens when the alarms are tested, so that they do not get worried and think it is a real alarm. The systems were in order and a record was made. The fire risk assessment must be reviewed as the new wing is now in use. There was a previous requirement that when staff have attended fire safety training in the home, that the date of the session is recorded above their initials. This has not happened and is a continuing requirement. The member of staff responsible for training in the organisation, who works in the home, has not had fire safety training recorded in the last quarter. All of the staff have still to receive fire safety training in house between October and December. The training officer has been discussing the fire safety training with the inspector outside of the inspection programme. COSHH records were in order, with safety data sheets in place for products in use in the home. Products are held safely in the home. Radiators in the new part of the building are not low surface temperature and need to be covered. Portable appliance test records are in place for electrical equipment that is used in the home. These are due for review in February 2006. St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 21 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 2 X X X Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 X X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Patrick`s House Score X X 1 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000060340.V266224.R01.S.doc Version 5.0 Page 22 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 3. 4. Standard YA2 YA17 YA20 YA20 Regulation 14(1) a b cd 17Sched 4.13 13(2) 13(2) Requirement Assessments must be made of the service user’s needs prior to admission. Menu records must show the range of meals that service users have eaten. Staff must sign to say they have administered medication every time it has been given. Two staff must sign the medication record sheet when entries or changes to medication have had to be handwritten. Service users complaints and any action taken must be recorded in the home. The service users’ complaints procedure must be robust and accessible to them. All staff must receive training in awareness of the No Secrets guidance and adult abuse. (Carried forward from last inspection. Due to be completed by 31st July 2005) Failure to meet this requirement may result in enforcement action. Not met by 31st October. The registered person must ensure that the recruitment DS0000060340.V266224.R01.S.doc Timescale for action 31/12/05 31/12/05 31/12/05 31/12/05 5. 6. 7. YA22 YA22 YA23 22(1)17 (2)Sch 4.11 22(2)(3) (4) (5) 13(6) 31/12/05 31/12/05 31/12/05 8. YA34 19 31/12/05 St Patrick`s House Version 5.0 Page 23 9. YA42 10. 11. YA42 YA42 practice in the home is safe and robust, showing evidence of decision making. 23(4) (d) When staff have attended fire 31/12/05 safety training, the actual date of training session must be recorded above the persons initials. (This was a requirement at the last inspection.) 23(4) (a) The fire alarm must be checked 31/12/05 on a weekly basis and a record made. 23(4)a b c The fire risk assessment must be 31/12/05 de reviewed and amended due to the extension in the home. 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. 4. 5. Refer to Standard YA2 YA6 YA16 YA17 YA22 Good Practice Recommendations It should be clear to service user what the consequences may be when they break the contract of the house rules that they have agreed to sign and follow. All care plans should have a similar format. Service users should have keys to the front door. Staff record light snacks on the menu sheet consistently. The manager should make arrangements for someone external to the team to periodically monitor and audit the financial records kept on behalf of service users. (Carried forward from the last two inspections.) Service users receipts should be attached to the monthly log sheets they are related to. The manager should consider keeping a compliments file. (Carried forward from the last two inspections) The complaint record should be checked three monthly. (Carried forward from the last two inspections) The manager should consult with care managers over the level and type of complaints that are expected to be recorded and responded to in the home. The decorating in the home should be improved to maintain the quality of the accommodation. Some additional curtaining should be provided to protect DS0000060340.V266224.R01.S.doc Version 5.0 Page 24 6. 7. 8. 9. 10. 11. YA23 YA23 YA23 YA23 YA24 YA24 St Patrick`s House 11. YA24 the privacy and dignity of service users who have floor length windows. The manager should obtain advice from an occupational therapist about adapting one ensuite into a walk in shower room. St Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Patrick`s House DS0000060340.V266224.R01.S.doc Version 5.0 Page 26 - 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. 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