Inspection on 02/11/05 for Stratton Road (27)

This inspection was carried out on 2nd 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stratton Road (27) 11/06/07

Stratton Road (27) 28/06/06

Stratton Road (27) 21/06/05

Stratton Road (27) 04/01/05

Stratton Road (27) 15/11/04

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 (27) 27 Stratton Road Pewsey Wiltshire SN9 5DY Lead Inspector Alison Duffy Unannounced Inspection 2nd November 2005 10:45 Stratton Road (27) DS0000028213.V261433.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 (27) DS0000028213.V261433.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 (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stratton Road (27) Address 27 Stratton Road Pewsey Wiltshire SN9 5DY 01672 562691 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 4 Category(ies) of Learning disability (4) registration, with number of places Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2005 Brief Description of the Service: 27 Stratton Road has recently increased its registration from three people with a learning disability to four. The additional vacancy has not however been filled and therefore three service users continue to live within the home at this time. 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. 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. Service users require a high level of staff assistance and communication is limited. The home has one member of staff on duty throughout the waking day and sleeping in cover is provided at night. Stratton Road (27) DS0000028213.V261433.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 between 10.45am and 4.45pm on the 2nd November 2005. On arrival, Mrs Sharon Wyatt, support worker was on duty and Miss Bev Britten Registered Manager was in the home although it was her day off. Mrs Lance also called into the home and some discussion took place regarding the existing wellbeing of service users and current staffing arrangements. Such issues are addressed within the main text of this report. Two service users were at home during the inspection and the Inspector was able to meet the third service user on her return from her day service. Care planning information, daily records, the fire log book, staffing rosters and recruitment documentation were also viewed. Due to complex need and communication difficulties, feedback regarding the service was limited. Much of the inspection was therefore based on observation and interactions and within this, it was clearly evident that all service users have developed excellent relationships with both Miss Britten and Mrs Wyatt. Both staff members were attentive and communicated well with a level of appropriate banter in response to individual personality. What the service does well: What has improved since the last inspection? What they could do better: Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 6 Current staffing levels and Miss Britten being an integral part of the staffing roster were discussed in detail with Mrs Lance and Miss Britten at the last inspection. Despite this and agreed timescales, made by taking into account staffing shortages with planned annual leave, there has been no change. It is therefore of great concern to the Inspector that the matter has not been addressed in any form. Existing staffing arrangements are severely restricting service provision. Insufficient flexibility does not enable in house activity or spontaneity with external events. Service users are therefore being restricted and their needs are not being fully met. Staffing arrangements are also affecting staff as their development is being restricted through no formal supervision and limited training. Review of sleeping in provision is required as it is not acceptable for staff to manage such a high level of disturbance within a sleeping in role. While Miss Britten is sole working as part of the working roster it is clear that management responsibilities are not being fulfilled. A high level of requirements and recommendations highlighted at the last and previous inspection remain outstanding. The majority have not received any attention in any form. Additional matters such as the neglect of fire safety also highlights the current situation. It is essential that Miss Britten is given time to concentrate on being the Registered Manager and gives focus to shortfalls identified within this report. 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 (27) DS0000028213.V261433.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 (27) DS0000028213.V261433.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 Despite a vacancy within the home, clear admission criteria is being adhered to in order to ensure an appropriate placement. EVIDENCE: The home has recently increased its registration from three service users to four. At present however, the additional vacancy has not been filled. Discussion took place with Miss Britten regarding this and it was evident that a clear admission procedure is in place. Full consideration is being given to the prospective placement ensuring that it complements the needs and behaviours of existing service users. Miss Britten continued to report that due to this, it has not been possible to fill the vacancy. At the last inspection and within the process to vary the home’s registration it was identified that an additional member of staff would be needed at the time of the admission. Miss Britten reported a clear awareness of this and agreed that this would be followed when required. Stratton Road (27) DS0000028213.V261433.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 Care planning is detailed yet some additions such as the management of night time disturbance would give greater consistency with care provision. Clarity within policies is required to ensure staff have the correct information to ensure service users’ safety. EVIDENCE: Each service user has a care plan, which contains detailed information. The plan is complemented with a record of health care input, body maps and charts such as weight monitoring. A number of risk assessments are also in place. Each service user has a daily diary, which reflects general mood, behaviour, wellbeing and activity. Although documentation gives a clear portrayal of need Miss Britten was advised to fully record management guidelines of discussed nighttime behaviour of one service user. This would ensure continuity of practice and enable further monitoring of the situation. Risk taking was not assessed on this occasion although at the last inspection it was identified that risk is generally associated with general health matters. Service users need full staff assistance with all daily living routines and do not go out unattended. The ‘absent without leave policy’ does not however reflect Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 10 this but implies a timescale before calling the police. Through discussion with Miss Britten and Mrs Wyatt, it was evident that due to service users’ vulnerability the police would be called immediately. This must be stated within the policy and therefore the unaddressed recommendation made at the last inspection has been changed to a requirement. Stratton Road (27) DS0000028213.V261433.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 While some structured opportunities are offered to service users, current staffing arrangements severely restrict spontaneous activity and occupation within the home environment. EVIDENCE: There have been no changes to service users’ daily activities since the last inspection. One service user continues to attend a day service four days a week and another attends for one session. One service user chooses not to attend any external services. When not at day services, time is generally centred on the home. This often means watching television or videos although one service user enjoys spending time in her room. Staff sole work and therefore do not have the opportunity for flexibility with internal or external activities. It was evident that appointments, such as a visit to the hairdresser are only possible if Miss Britten or another member of staff provides cover for the home at the end of their shift or on a day off. Spontaneous walks or trips out are not possible. At the last inspection it was noted within a review record that staffing shortages have restricted activities such as swimming. Miss Britten reported that this remains the same and although additional staffing would be beneficial, it is not available at this present time. Due to this, service Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 12 users are restricted in opportunities available to them. Further consideration must therefore be given as to how this may be addressed. Stratton Road (27) DS0000028213.V261433.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): 18 and 19 Service users’ health care is well managed and all personal care support is well documented and given in a competent manner. EVIDENCE: Service users continue to require a high level of staff support with all daily living routines. Such care was given during this inspection in a confident manner with particular attention to privacy and dignity. One service user received support during a seizure and this was undertaken quietly and competently. Clear routines are demonstrated in care planning information and assistance required is evident. A key worker system is in operation yet staff work well with all service users and appear very aware of individual needs. Documentation demonstrated a range of input from various health care services. Mrs Wyatt and Miss Britten both described on going assessment and intervention regarding one service user’s review of behaviour and medication. Various strategies have been applied and monitoring and review is currently anticipating further progress. Service users attend the local surgery as required and gain specialist treatment such as dentistry through referral. 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 Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 14 Monitored Dosage System. It was agreed that this should reduce workload and risk of error, which in turn should enhance efficiency. Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Information regarding the complaint procedure continues not to be freely available to individuals who may act on behalf of service users. The home’s adult protection systems are insufficient at this time to fully protect service users. EVIDENCE: The home has a complaints procedure within each service user’s file. However due to limited communication and understanding, service users would be unable to raise their discontentment and therefore rely on staff or other representatives to identify any concerns. At the last inspection it was identified that not all family members were aware of the home’s complaint procedure. A requirement was therefore made to address this matter although to date, this has not received attention. As service users rely on others to identify their concerns, this requirement has been repeated. Miss Britten reported that there have been no complaints reported to the home. There have been no formal complaints reported to CSCI. The home has systems in place to record complaints as required. 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 although one member has undertaken a session within her NVQ qualification. 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 Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 16 behalf of service users. Miss Britten has recently reviewed the management of this and a member of staff now countersigns all expenditures. A regular audit is undertaken and receipts are chronologically attached to balance sheets. During this inspection, all cash amounts were checked against the balance sheets. One discrepancy was noted. Miss Britten reported that a member of staff had withdrawn money for an activity but had not recorded such. This was confirmed when the member of staff was contacted and rectified the error during the inspection. Miss Britten was informed of the need to ensure that staff record all transactions at the time of their undertaking. 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. Miss Britten did confirm however that all journeys undertaken by service users are now recorded and can be cross-referenced as required. Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 and 30 27 Stratton Road is comfortable, homely and domestic in style. All areas appear well maintained and recent developments visually improve the environment. EVIDENCE: 27 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 with dining area that has patio doors opening onto an enclosed garden. The hall, landing and lounge area have recently been fitted with new carpets and the dining room has had new flooring. This has improved the space and makes cleaning spillages easier. The home has a large kitchen and 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. Low surface temperature radiators are in place and the hot water is controlled centrally. A random sample of hot water outlets are regularly checked and a record is maintained. There is a large summerhouse in the rear garden that is currently used as a storage area. At the last inspection Miss Britten reported that she was hoping Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 18 to turn the area into an activity room. To date however these plans have not been implemented. Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 19 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, 33, 35 and 36 Staffing arrangements at this time are restricting opportunities to service users and not enabling individual needs to be met. Staff are up to date with their mandatory training yet in house training is severely restricted due to Miss Britten undertaking support worker responsibilities on a lone working basis. Staff supervision is given insufficient priority, which compromises the development of the home, the staff and care provision. EVIDENCE: At present the home has a core group of three staff including Miss Britten. Each member sole works throughout the waking day and provides sleeping in provision at night. As stated earlier in this report, appointments such as the hairdresser or GP are undertaken when Miss Britten or another member of staff can stay on after their shift. Any spontaneous activity such as going out for a walk is not possible unless additional cover is sought. Due to this when not at day services, service users’ time generally involves watching television in the lounge. In order to give service users greater opportunities and continue with interests such as swimming, a requirement was made at the last inspection to review staffing levels accordingly. This has not been undertaken. Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 20 The home continues to provide sleeping in cover at night although nighttime disturbance is high. At the last inspection a requirement was made to ensure that night disturbance continues to be monitored and if required, the sleeping in provision should be replaced with a waking night. Within the inspection it was noted that disturbances are clearly being recorded although there have been no changes to the deployment of staff. Miss Britten reported that additional funding has been agreed in principle and therefore consideration must be given as to how this can be effectively used in order to meet the individual needs of the service user. As stated earlier in this report, the home is registered for four service users although at this time there are only three. At the time of the next admission however, staffing levels must be increased to two staff members throughout the waking day in order to meet service users’ complex needs. At present one member of staff has NVQ level 2 and is wanting to progress to level three. Both staff members have undertaken first aid, food hygiene and epilepsy and one member of staff has recently completed a lengthy medication course. Adult protection training however remains outstanding. Miss Britten regularly meets with staff on an informal basis yet formal supervision has not been addressed. This has been highlighted at previous inspections although due to Miss Britten sole working, arranging the sessions has not been possible. A number of new members of staff have joined the organisation since the last inspection. These members commenced employment in the other homes within the organisation although may cover some shifts at 27 Stratton Road in the future. The personnel records identifying the recruitment process were viewed and a number of shortfalls were identified. However as the candidates were not recruited specifically for the home, the process was not assessed with a standard met score on this occasion. Discussion did however take place regarding ways to improve the process. This included ensuring that the home requests all references. Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 21 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 and 42 Removing Miss Britten from being an integral part of the working roster is essential to ensure that management responsibilities are fulfilled. Addressing previous requirements and implementing systems such as quality assurance have been significantly neglected through Miss Britten having insufficient management time. Priority must be given to fire prevention systems in order to ensure the safety of service users. EVIDENCE: Miss Britten continues to undertake her full working time undertaking care provision on a sole working basis. Through discussion it was evident that Miss Britten undertakes the role of a support worker and has no time to address management responsibilities including staff supervision, training and compliance with regulation. At the last inspection Mrs Lance reported that this matter would be addressed and Miss Britten would be given greater flexibility. A requirement was therefore made with a timescale of 31st October 2005. This Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 22 was not however, achieved. Within this inspection Mrs Lance agreed it would be started week beginning 6th November 2005. 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. It was identified at the last inspection 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 is not 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. The environment appears to be well maintained and radiators have cool touch surfaces. Hot water is controlled centrally although the temperatures are regularly monitored and recorded. A number of risk assessments are in place. At the last inspection, a hand washing risk assessment was in need of review. A fire risk assessment was also needed. To date these have not received attention. The fire log book demonstrated that the last fire safety checks had been undertaken in June 2005. The last fire drill was also in June and there was no evidence of any fire instruction. Miss Britten was aware of the shortfalls and reported attention would be given to all areas. Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 23 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 3 X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 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 2 13 X 14 2 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 3 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Stratton Road (27) Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 2 X 1 X X 2 X DS0000028213.V261433.R01.S.doc Version 5.0 Page 24 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. This was identified at the last inspection. The Registered Person must ensure that consideration is given to how opportunities for leisure activities in and outside of the home can be provided in relation to staff sole working. This was identified at the last inspection. The Registered Person must ensure that all family members are given details of the homes complaint procedure. 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 subsequent inspection. The Registered Person must DS0000028213.V261433.R01.S.doc Timescale for action 09/12/05 2 YA12 and YA14 16(2)(n) 31/12/05 3 YA22 22 09/12/05 4 YA23 13(6) 31/01/06 5 YA23 13(6) 02/11/05 Page 25 Stratton Road (27) Version 5.0 6 YA23 13(6) ensure that all transactions regarding service users’ monies are fully recorded at the time of their undertaking. 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 give consideration as to the staffing provision required in order to effectively meet the identified service user’s nighttime care needs. The Registered Person must ensure that written references 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 ensure that a formal system of recorded staff supervision is developed and maintained. This was identified at the last and subsequent inspection. The Registered Person must ensure that the Registered Manager is not an integral part of the working roster. 31/12/05 7 YA33 18(1)(a) 09/12/05 8 YA34 13(6) 02/11/05 9 YA36 18(2) 31/01/06 10 YA37 18 07/11/05 11 YA39 24 12 YA41 12(1)(a) This was identified at the last and subsequent inspection. The Registered Person must 31/01/06 ensure that a system to improve the quality of the home is devised and implemented. The Registered Person must 31/12/05 ensure that all policies and procedures are specifically related to service provision. DS0000028213.V261433.R01.S.doc Version 5.0 Page 26 Stratton Road (27) 13 YA42 23(4) This was identified at the last inspection. The Registered Person must ensure that a fire risk assessment is carried out. 09/12/05 14 YA42 This was identified at the last and subsequent inpection. 23(4)(c)(v) The Registered Person must (d)(e) ensure that fire safety checks, fire drills and fire instruction are undertaken as required and documented accordingly. 02/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA9 Good Practice Recommendations The Registered Person should ensure that written guidelines are available to staff in relation to the identified service user’s disturbances during the night. The Registered Person should ensure that the risk assessment involving hand washing is clarified. This was identified at the last inspection. 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. 3 YA39 Stratton Road (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 27 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 (27) DS0000028213.V261433.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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