Inspection on 10/11/05 for Stratton Road (20)

This inspection was carried out on 10th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stratton Road (20) 11/09/07

Stratton Road (20) 13/11/06

Stratton Road (20) 22/06/05

Stratton Road (20) 26/02/05

Stratton Road (20) 16/11/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Stratton Road (20) 20 Stratton Road Pewsey Wiltshire SN9 5DY Lead Inspector Alison Duffy Unannounced Inspection 10th November 2005 16:00 Stratton Road (20) DS0000028314.V261441.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 Stratton Road (20) DS0000028314.V261441.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. Stratton Road (20) DS0000028314.V261441.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stratton Road (20) Address 20 Stratton Road Pewsey Wiltshire SN9 5DY 01672 564957 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) Landlace Care Homes Ltd Miss Beverley Britten Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Stratton Road (20) DS0000028314.V261441.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 2005 Brief Description of the Service: 20 Stratton Road is a residential care home which accommodates three service users with a learning disability. The home is one of three residential care homes owned by Landlace Care Homes Ltd. Miss Bev Britten is the Registered Manager and Mrs Nan Lance is the responsible individual. Miss Britten is also a Registered Manager for another home within the organisation. Mrs Lance works closely with her daughter, Miss Britten. The home is located within a residential area of Pewsey and is within walking distance of local amenities. The property is semi detached and furnished to a good standard. Service users have single room accommodation on either the ground or first floor. The home has one member of staff on duty throughout the waking day and sleeping in cover is provided at night. Stratton Road (20) DS0000028314.V261441.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 10th November 2005 from 4pm – 6pm. On arrival at the home, Mrs Ann Stagg, support worker was on duty and all service users returned at approximately 4.20pm. Time was spent with service users and care-planning information was viewed. As stated earlier, 20 Stratton Road is one of three homes within the organisation. Personnel information and residents’ personal allowances are stored within another of the homes, 27 Stratton Road. Due to this, these issues were addressed within the inspection of 27 Stratton Road on 2nd November 2005. The findings however are included in this report. Within the inspection on 10th November 2005, the home was very hectic with service users needing to be out of the house by just after 6pm to catch the bus to Gateway Club. The Inspector was able to observe individual routines and the serving of the evening meal. During this time service users were fully involved and talked enthusiastically of their day and their lives in general. What the service does well: What has improved since the last inspection? What they could do better: Stratton Road (20) DS0000028314.V261441.R01.S.doc Version 5.0 Page 6 Although meeting previous registration authority staffing guidelines, sole working compromises the individuality of service users. Greater attention must be given to ensuring a more robust recruitment procedure. Systems such as quality assurance must be implemented although additional research into the topic may be of benefit before commencement. Although it is acknowledged that Miss Britten is now spending more time within the home, this must be increased sufficiently in order to fulfil management responsibilities. Many requirements identified at the last inspection remain outstanding and therefore it is essential that Miss Britten is given time to focus on such shortfalls and fulfil her role as the Registered Manager. Timescales have been revised, although in the absence of attention, enforcement action will be considered. This will be determined through an additional visit after the stated timescales have expired. 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. Stratton Road (20) DS0000028314.V261441.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 Stratton Road (20) DS0000028314.V261441.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): It was believed not to be appropriate to assess the above key standard relating to assessment as all service users have lived at the home for many years and changes are not expected. Service users reported being settled, content and happy with the service received. EVIDENCE: Due to the long-term nature of all placements, it is not anticipated that there will be any changes in the service users living within the home. All service users have lived within the home for many years and therefore have built established relationships. All reported being very happy and a recent review record of one service user demonstrated that needs are being satisfactorily met. Stratton Road (20) DS0000028314.V261441.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7 Care planning demonstrates assistance required yet does not reflect the involvement of service users or their representatives. Service users are encouraged to make their own decisions although current staffing arrangements give some restrictions with meeting individual need. Clarity within policies is required to ensure staff have the correct information to ensure service users’ safety. EVIDENCE: All service users have a plan of care, which details an assessment of need and levels of assistance required. Preferred routines are stated and these are reflected within detailed daily diary entries. A number of risk assessments are in place and a record of matters such as weight are evident. At present there is no evidence of service users’ involvement within the development of plans. Miss Britten is advised to develop this area and also involve family members or representatives as appropriate. It was apparent that personal details about service users continue to be placed within the home’s communication book. Miss Britten is advised to ensure all staff record such information appropriately. Stratton Road (20) DS0000028314.V261441.R01.S.doc Version 5.0 Page 10 Through discussion with service users it was evident that communication is part of every day life. There is regular informal discussion during mealtimes, which includes matters such as forthcoming events. Service users reported that they are encouraged to be involved in all aspects of the home. This includes laundry, vacuuming, polishing, emptying the dishwasher and putting the shopping away. One service user undertook the task of laying the table during the inspection. At the last inspection it was highlighted that service users had requested to be more involved with meal preparation. Mrs Stagg reported that service users do generally assist with cooking although due to time restraints, staff undertake the role on occasions. Although it was evident that service users are encouraged to make decisions, some restrictions are in place due to staffing arrangements. For example, due staff sole working it is generally expected that service users undertake external activities together rather than on an individual basis. Risk taking was not assessed in detail on this occasion although through documentation it was evident that service users are encouraged to be as independent as possible. At a previous inspection Miss Britten was advised to fully record the assessment process undertaken when confirming service users’ competence. For example, within a risk assessment of walking to the shops, regular monitoring of road safety is stated. There is however little written evidence of such monitoring. At the last inspection it was recommended that clarity should be given to the ‘absent without leave’ policy. To date however this has not received attention. When discussing the policy during the inspection of 27 Stratton Road, it was evident that staff would notify the police immediately in relation to any service user within the organisation. This must therefore be agreed and confirmed within the policy as at present timescales are given before the police are contacted. Due to the possible risks of service users being unattended, the unaddressed recommendation made at the last inspection has been changed to a requirement. Stratton Road (20) DS0000028314.V261441.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): 12 and 14 Attendance at day services is enjoyed and all placements appear productive and relevant to meeting individual needs. While service users have a range of opportunities for external activity, current staffing levels restrict individual time and individual preferences. EVIDENCE: There have been no changes to the daytime activities of service users. Two service users attend a day service each day during the week. Both talked of this with enthusiasm stating that trampolining had been good that day. Both service users reported enjoying the session of cooking their own lunch and getting out and about. One service user attends their day service on a sessional basis. When not undertaking sessions, time is spent in other homes within the organisation. Although it was reported that this is undertaken in order to spend time with others, it was also mentioned that spending time watching television alone in private accommodation would probably be preferred. Due to current staffing arrangements however, this probable preference would not be an option. Stratton Road (20) DS0000028314.V261441.R01.S.doc Version 5.0 Page 12 Service users attend various clubs such as Gateway and Open Minds. Service users said they enjoy both clubs, as they are able to meet up with friends. The Gateway Club also facilitates a high level of additional activity and therefore service users said they are often out. On the night of the inspection all service users were getting ready to go to Gateway and the local bus service was being used. Through discussion it was evident that service users also enjoy leisure activities within the home such as watching sport on television, music and puzzles. While a number of opportunities are available, service users generally undertake activities together. Stratton Road (20) DS0000028314.V261441.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): 19 Service users’ health care is well managed and services are accessed as required. EVIDENCE: Service users generally maintain a good standard of health and therefore input from health care professionals is minimal. Documentation highlights various interventions, including a number of GP appointments. Care planning information also details responsibilities of matters such as nail care. Service users give their consent to preventative measures including the annual flu injection and specialist input is received on a referral basis. One service user reported that the staff are very good when you are not well and will take you to see a doctor. Medication was not assessed on this occasion although Miss Britten reported that arrangements are currently being made to change the system to that of a Monitored Dosage System. It was agreed that this should reduce workload and the risk of error, which in turn should enhance efficiency. Stratton Road (20) DS0000028314.V261441.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): 23 The home’s adult protection systems are insufficient at this time to fully protect service users, as not all staff have had adult protection training. The management of service users’ personal monies is organised, accurate and has significantly improved from the last inspection. EVIDENCE: Complaints were not addressed on this occasion as satisfactory procedures were noted at the last inspection. Service users reported that they would tell a member of staff if they were unhappy. At the last and previous inspection it was noted that some staff had not undertaken adult protection training. In order to address this Miss Britten had purchased an in house adult protection training pack. To date however, training sessions have not been arranged. This requirement has therefore been repeated and must be addressed as a matter of urgency. Service users do not manage their financial affairs and all have appointees with their placing authorities. Some small amounts of money are kept securely on behalf of service users. At the last inspection a high level of errors were noted and the system was unorganised and difficult to follow. In order to address this, all money is now stored securely within 27 Stratton Road. The system is much improved although its storage may be restrictive as in the event of needing money, contact must be made with the other home. During the inspection one service user was asked to walk the short distance to the home to collect money for the evening entertainment. During the inspection of 27 Stratton Road, all cash amounts were checked against balance sheets. All were found to correspond. Receipts were also attached accordingly and two Stratton Road (20) DS0000028314.V261441.R01.S.doc Version 5.0 Page 15 signatures were evident in relation to expenditure. Miss Britten reported that regular audits are also made in order to ensure accurate transactions. At the last inspection a requirement was made to develop a policy for transport, contributing to gifts and subsidising staff when out. Miss Britten was unsure whether this had been undertaken as Mrs Lance undertakes all policies. Confirmation is therefore required. Stratton Road (20) DS0000028314.V261441.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, 28 and 30 The home is comfortable, homely, clean and well maintained. All areas are furnished to a good standard and meet service users’ needs. EVIDENCE: 20 Stratton Road is a semi-detached house within a residential area of Pewsey. The home blends in well with others in the vicinity and is a short walk from local amenities. A local bus service is available and easily accessible. Private accommodation consists of single rooms, which are located on the ground and first floor. There is a pleasant lounge, which has patio doors opening onto an enclosed garden. There is a large kitchen/diner with a separate utility room. The facilities continue to meet the needs of service users and on the day of the inspection all areas were clean and odour free. Hot water is controlled centrally. A random sample of hot water outlets are regularly checked and a record is maintained. Radiators are at this time uncovered and risk assessments are in place. Stratton Road (20) DS0000028314.V261441.R01.S.doc Version 5.0 Page 17 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): 33, 34 and 36 Staffing shortages have been resolved and the roster is now covered in line with previous registration authority guidelines. Opportunities to meet service users’ individual needs are at times restricted due to there being one member of staff on duty. Staff supervision has been minimal, yet attention is now being given to establishing a formal system. EVIDENCE: At the last inspection significant staffing shortages were a cause for concern. Additional staff have since been recruited and an existing member of staff has returned from sick leave. The staffing roster is therefore now covered. Staff continue to sole work while service users are at home. Staff commence their shift at 4pm until 10pm and undertake sleeping in provision between the hours of 10pm and 7am. Staff then work until 9am when service users go off to their day services. Although staffing levels are maintained in line with previous registration requirements, little flexibility is available to address service users’ individual social interests. A requirement was made at the last inspection to address this matter although there have been no changes to the staffing arrangements at this time. Stratton Road (20) DS0000028314.V261441.R01.S.doc Version 5.0 Page 18 Training was not examined on this occasion although at the last inspection it was noted that all except one member of staff had an up to date first aid certificate. Three staff had completed fire training and two had undertaken a course on epilepsy and food hygiene. Within discussion with Miss Britten during the inspection of 27 Stratton Road it was evident that there continues to be some reluctance to training and such shortfalls have not been addressed. Miss Britten was informed of the need to address this, as all staff must be fully trained in the work they are expected to carry out. As stated above, a number of new staff have been recruited to the organisation and one of these members is deployed to the home. All personnel records are stored within 27 Stratton Road and therefore these were viewed during the earlier inspection on the 2nd November 2005. It was noted that the files were incomplete although Miss Britten reported that all checks had been undertaken. Not all applications possessed written references and in the cases of references being present, these were insufficient. Some were addressed to ‘whom it may concern’ and others were not dated. Some did not include current employers and in one instance headed paper was not used, although due to the organisation, this would have been expected. Through discussion it was evident that prospective candidates are asked to gain their own references. This practice must therefore be reviewed and the home must directly request all references. At the last and previous inspection it was noted that staff were poorly supervised as Miss Britten was spending limited time within the home. This was once again discussed with Mrs Lance and it was agreed that from 6th November 2005, Miss Britten would be released from sole working in another of the homes within the organisation, in order to concentrate on 20 Stratton Road. Within this inspection it was noted that the first formal supervision session had taken place and sessions for other staff had been arranged. Stratton Road (20) DS0000028314.V261441.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 and 39 While it is acknowledged that Miss Britten has commenced formal supervision within the home, additional time must be given to enable clear leadership and the fulfilment of management responsibilities. Addressing previous requirements and implementing systems such as quality assurance have been significantly neglected through Miss Britten not spending sufficient time within the home. EVIDENCE: As stated above, at the last and previous inspection it was highlighted that Miss Britten has spent limited time within the home. This meant management responsibilities were being unfulfilled and leadership was poor. Although aware of this, Miss Britten was sole working in another home within the organisation and therefore time was restricted. Through further discussion with Mrs Lance during the inspection of 27 Stratton Road, it was agreed that Miss Britten would commence staff supervision the week beginning 6th November 2005. This has been achieved although Miss Britten must continue to spend a high Stratton Road (20) DS0000028314.V261441.R01.S.doc Version 5.0 Page 20 level of time within the home in order to ensure systems are established. Time must also be given to shortfalls identified within this and the last inspection. Miss Britten is currently undertaking NVQ level 3 and hopes to finish this soon. After a short break, Miss Britten is anticipating undertaking the Registered Managers Award. Miss Britten reported that due to time restrictions, no attention has been given to quality assurance systems. Through discussion it was apparent that the subject is not a specific strength of the home and therefore greater knowledge would be of benefit. At the last inspection it was identified that the home has a number of well written, informative and easy to read policies and procedures. A requirement was made however to ensure that all relate totally to existing care provision. For example, within the management of aggression policy, information is given regarding panic alarms, which is not relevant to the home. The ‘absent without leave policy’ as stated earlier in this report, mentions timescales before contacting the police, which appears not to be relevant to existing service users. Although a requirement was made to address these issues, there does not appear to be any evidence of any such attention. Health and safety was not assessed on this occasion although a requirement was made at the last inspection, to discuss requirements with the fire officer regarding propping open fire doors. Due to the need of easy accessibility, the kitchen doors need to be open and therefore a mechanical closing device would be beneficial. Attention has not however been given to this matter and when service users are at home the doors remain propped open. It was also agreed at the last inspection that the content of some risk assessments would benefit from clarification. For example an assessment reported that a service user was able to tell the difference between hot and cold when running the bath. It did not however assess whether the service user was able to satisfactorily mix the water to a safe temperature. Hot surfaces such as radiators have been addressed within the risk assessment process and a low risk was identified. Within such assessments it was recommended to also address matters such as mobility rather than solely concentrating on service users’ ability to differentiate between hot and cold. Although a requirement was made to address these matters there have been no changes to the risk assessments. Stratton Road (20) DS0000028314.V261441.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 X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 2 X 1 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Stratton Road (20) Score X 3 X X Standard No 37 38 39 40 41 42 43 Score 2 X 1 X X X X DS0000028314.V261441.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 Standard YA9 Regulation 13(4)(c) Requirement The Registered Person must ensure that the missing person procedure is reviewed and police involvement is clarified. The Registered Person must ensure that staffing levels enable all service users to have opportunities for individual leisure activities in and outside of the home. This was identified at the last inspection. The Registered Person must ensure that all staff receive adult protection training. This was identified at the last and previous inspection. The Registered Person must ensure that the policy regarding service users’ payment of transport and subsidising staff when out, is readily accessible and understood by staff. This was identified at the last inspection. The Registered Person must ensure that written references DS0000028314.V261441.R01.S.doc Timescale for action 09/12/05 2 YA14YA12 16(2)(n) 31/12/05 3 YA23 13(6) 31/01/06 4 YA23 13(6) 31/12/05 5 YA34 13(6) 10/11/05 Stratton Road (20) Version 5.0 Page 23 6 YA35 18(1)(a) are requested directly from the stated referees. References brought with the prospective member of staff must not be accepted unless fully verified. The Registered Person must 31/01/06 ensure that all staff have sufficient training to demonstrate competence within their role. This must include first aid and food hygiene. This was identified at the last inspection. The Registered Person must ensure that sufficient time is spent within the home to portray a clear sense of leadership and fulfil management responsibilities. This was identified at the last inspection. The Registered Person must ensure that a system to improve the quality of the home is devised and implemented. The Registered Person must ensure that all policies and procedures are specifically related to service provision. This was identified at the last inspection. The Registered Person must ensure that fire doors are only propped open with a mechanical device linked to the fire alarm system. Confirmation of such devices must be discussed with the Fire Officer. 7 YA37 12(1)(a) 10/11/05 8 YA39 24 31/01/06 9 YA41 12(1)(a) 31/12/05 10 YA42 12(1)(a) 31/12/05 11 YA42 13(4)(c) This was identified at the last inspection. The Registered Person must 31/12/05 ensure that further clarification is given to the risk assessments relating to bathing and radiators. DS0000028314.V261441.R01.S.doc Version 5.0 Page 24 Stratton Road (20) This was identified at the last inspection. 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 6 Refer to Standard YA6 YA6 YA9 YA34 YA34 YA39 Good Practice Recommendations The Registered Person should ensure that the communication book is not used to record information about service users. The Registered Person should ensure that service users are involved in their care planning process and this is evidenced accordingly. The Registered Person should ensure that there is documentary evidence of the assessment process, which highlights service users’ competence within areas of risk. The Registered Person should ensure that one written reference is received from the candidate’s present employer. The Registered Person should ensure that all references are personally addressed and do not state ‘to whom it may concern.’ The Registered Person should ensure that the topic of quality assurance is researched in order to assist with the implementation of the home’s individual system. Stratton Road (20) DS0000028314.V261441.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 Stratton Road (20) DS0000028314.V261441.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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