Inspection on 08/02/06 for Sussex House

This inspection was carried out on 8th February 2006.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sussex House 14/09/09

Sussex House 15/09/08

Sussex House 03/07/07

Sussex House 04/07/06

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Sussex House 36 Princes Road Cleethorpes North East Lincs DN35 8AW Lead Inspector Stephen Robertshaw Unannounced Inspection 8th February 2006 09:30 Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 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 Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 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. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sussex House Address 36 Princes Road Cleethorpes North East Lincs DN35 8AW 01472 694574 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) Amina Teja Mrs Anne Hanslip Care Home 24 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (24) of places Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Sussex House is a residential care home registered for 24 service users in the category of mental disorder. The building is old and has been extended on several occasions. There is no scope for further development. The service users accommodation is provided over two floors. There is a passenger lift to the first floor. Sussex House is close to the centre of Cleethorpes and is within five minutes walk of the train station and the beach. Local amenities include shops, public houses, GP surgeries and parks. Regular public transport is easily accessible from the home and is also available to the adjoining town of Grimsby. The home have applied to the Commission to vary their registration as approximately 50 of the service users are now close to or over 65 years old and wish to remain in the home were they believe their needs are being well met. The two new proprietors have been approved by the Commission to support the current proprietor in the management, administration and running of the home. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection to Sussex House was unannounced and took place on 8th February 2006. The inspection was over seven hours and the information for the report was gathered through the inspector reading documentation in the home, interviewing management and staff and having discussions with the service users. The service user appeared to be very happy with the care that they received at the home. What the service does well: The service users stated to the inspector that the care that they receive in the home is very good and that all of their needs were met. The choice and quality of food provided at the home is good. Service users confirmed to the inspector that if they do not want the food that s on the menu they are provided with an alternative that they like. This was observed by the inspector to be the actual practice in the home. Staff understand the needs of the service users and receive all of the appropriate mandatory training and training that that is specific to the needs of service users with mental health problems. Service users stated to the inspector that they are very happy with the individual accommodation that is provided for them and confirmed that they are able to personalise their own areas. The service users are provided with support and encouragement to access activities in the local community. Care plans and risk assessments identified that the service users are supported to maintain their relationships with their families and friends and that the service users have clear freedom of movement in their daily routines that promotes their independence. The home is kept clean, tidy and was free of offensive smells. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 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. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 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 Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 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): 1,2,3, and 4 The service users are provided with the opportunity to choose to live at the home and have choice in all areas of their lives while resident at Sussex House. EVIDENCE: The inspector observed the statement of purpose for the home. This included all of the information required by the regulations, however, it needed to be updated to include the details of the new additional proprietors to the home. The inspector looked at the case file information for three of the seventeen service users living at the home. These all included a comprehensive assessment of their needs that had been completed by the funding care management teams. Two of the case files were for two recent admissions in to the home. The home had completed their own pre-admission assessments, however, they were very limited in the information that was recorded in relation to the service users individual needs. The staff completing the pre-admission assessments must include how the service users needs effect them and how they would need to be met. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 9 A recent emergency admission to the home had their needs assessed by the home within forty-eight hours of their arrival. The service users spoken to by the inspector were very positive in relation to the care and support that they received through the home. They stated that ‘the staff help them with everything’ with everything that they need. New prospective service users to the home are provided with the opportunity to visit the home before they decide to stay there on a more permanent basis. On their visits they are encouraged to meet all of the other service users and the staff group. The visits to the home include a half days and meals to overnight accommodation. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 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 and 8 The staff ensure that the service users individual needs are met and that they are provided with choice throughout their daily lives. EVIDENCE: The inspector observed that individual care plans for three of the service users. These had all been evaluated on a minimum of a monthly basis to make sure that the home was still meeting their needs. This is a big improvement of the previous evaluation of the care plans at the home. The evaluation of the care plans included the identification of what changes needed to be made to continue to meet the individual service users needs at the home. The care plans did not restrict any movement for the service users unless the care plan was supported through a clear risk assessment. Service users spoken to by the inspector were aware of their care plans and state that the staff helped them to ‘meet ‘ all of their identified needs. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 11 The service users confirmed that they had been involved in the development of their care plans and they were also able to be present and involved when the care plans are reviewed. All of the case files observed by the inspector also included the care plans form the funding authorities that had been developed through their care management assessments. All of the needs identified in the homes care plans related closely to those provided through the care management care plan and summary of need. No service users living at the home were supported through the court of protection or power of attorney to help them with their financial affairs. Records of service users meetings, direct observation by the inspector and discussions with service users supported the fact that the service users are provided with choice throughout their daily lives at the home. This included times to rise from and retire to bed, what to eat and where to eat it and whether or not to become in any organised activities in the home or in the community. Although the service users stated that they have regular meetings with the staff to air their views these are not recorded on a regular basis and should be to allow the service users to add their views to their care and their opinions of the management and staff working at the home. This information could also contribute towards the homes quality assurance programme. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15,16 and 17 The service users are encouraged to develop and maintain their own personal lifestyles at the home. EVIDENCE: The service users are encouraged to become involved in adult education in the local community, however, due to their poor commitment and concentration the courses are not always completed by individual service users. Service users stated to the inspector that they are ‘free’ to go out in to the local community at any time and when they require staff support to do this then this is provided. Activities in the home may appear to be limited, however, the service users stated to the inspector that the frequency and content of activities available were appropriate to their needs and were stimulating. The home does not provide the service users with a seven-day annual holiday as part of their basic contract price. All of the service users spoken with stated Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 13 that they would not want this but preferred shorter activities and in smaller groups. The care files read by the inspector included clear details of any contact that the service users have with their family and friends. The service users spoken to by the inspector said that ‘the staff are very good’ at supporting them to maintain these relationships. The individual care plans and discussions with the service users showed that they are supported and encouraged to access opportunities to meet people outside of the home that do not have mental health problems. The care plans and direct observations carried out by the inspector confirmed that the service users are promoted to develop their personal independence skills. If service users have the capacity it is identified in their care plans that they should be supported to maintain their personal spaces in the home and that they should also be supported to undertake their own laundry tasks. Some service users said to the inspector that they were very happy at the home being supported to keep their own rooms tidy and doing their own washing and ironing. The inspector ate lunch with a group of the service users. The meal was well presented and the service users stated that they were always ‘very happy with the food’ at the home. They also confirmed that they are always provided with meals that were filling for them and that choices were always available. Service users confirmed that they are regularly asked what they would like to be included on the homes menus. The table clothes were in need of replacement as they were covered with cigarette burns. The place settings also need replacing as they were Christmas place settings. The dining chairs were very uncomfortable and the registered person should consider replacing them. The manager of the home confirmed that the dining tables are due to be replaced with new tables. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 The personal and healthcare needs of the individual service users are met through the services provided by the home and the support received through external agencies. EVIDENCE: Sussex House does not provide nursing care to the service user group. It is only registered for residential care. The service users case file records and discussions with service users supported that their individual healthcare needs are met through healthcare professionals that are based in the community. This included GP’s, psychiatrists and community psychiatric nurses. Records observed by the inspector and interviews with the staff showed that the home has good working relationships with the outside professionals that support the healthcare needs of the service users. Individual care plans identified any contact that service users have with healthcare specialists. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 15 Service users confirmed to the inspector that they choose their own clothes to wear but some stated that they had to be occasionally encouraged to change the clothes that they wear as they do not always do this for themselves. The service users do not require very may mobility aids to support them around the home. However, they have a bath chair and a manual hoist available to them. The maintenance records for these pieces of equipment were observed by the inspector and were up to date. Staff stated that they had received training in the use of the bath chair and hoist. All of the care staff working at the home have already completed or are enrolled on an accredited medication course. The staff audit the medication in the home two times every day. All of the medication records were up to date and were accurately recorded. All unused medication is recorded and is returned to the pharmacy as appropriate. Staff spoken with by the inspector were aware of the need to keep medication of deceased service users for seven days in case of a coroners inquest. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a clear and easy to access complaints procedure and the service users welfare is protected at the home. EVIDENCE: The records in the home and at the CSCI office showed that there had been one POVA investigation at the home in the last twelve months. The complaint was in relation to the meals provided at the home and the food being prepared being out of date. The complaint was not upheld. Since the last inspection there were two complaints recorded and dealt with internally by the management of the home. The complaints were fully recorded including the detail of the complaint, the outcome of the investigation and an action plan. The staff receive protection of vulnerable adult training through their induction at the home and it is included in their NVQ training. All of the staff spoken to by the inspector were aware of adult protection issues and knew how to report suspected abuse. Service users that were identified to display aggressive behaviours had this identified in their care plans and included a behaviour management plan. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 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): 24,25,26,27,28,29 and 30 The environment provided at Sussex house is appropriate to meet the needs of the service users. EVIDENCE: The home provides a homely atmosphere that is generally comfortable and provides a safe environment for the service users to live in. The home includes twenty single bedrooms of which thirteen include en-suite facilities. The home also includes two double bedrooms. All bedrooms at the home are currently being used for single occupation. Separate to the en-suite facilities are three additional bathrooms that also include toilet facilities and two separate toilets. The homes redevelopment and maintenance plan has stated to redecorate the individual service users rooms. The service users that’s rooms had already been completed stated that they had been consulted in how their rooms would be decorated. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 18 There is no use of CCTV in the home or in its grounds. A tour of the premises by the inspector confirmed that the service users had been given the opportunity to personalise their own rooms with small items of furniture and personal pictures and ornaments. Service users spoken to by the inspector stated that they were very happy with their individual rooms and the communal areas. The management of the home has begun to have the environment decorated. The lounge area at the end of the dining room is now much lighter and is more appealing for the service users to use. The dining room is dimly lit from florescent tube lighting. The proprietors should consider updating this lighting to a more appropriate form that id domestic in character and provides more appropriate light to the area. There are very few environmental adaptations required by the service users living at the home. Maintenance and service records were observed for the equipment that was in place. The tour of the premises confirmed that the home is clean, hygienic and was free of any offensive smells. The home employs two domestic staff that undertake all of the domestic tasks at the home with some support of the night staff. The homes washing machine is programmable to disinfection and sluicing standards. This has recently been fitted with an automatic system for filling the washing and conditioning materials. This is more appropriate for the staff as they no longer have to handle the caustic substances and would be safer for the service users to use if they were doing their own washing as part of their development of their independence skills and was identified in their care plans. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 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): 31,32,33,34,35 and 36 The service users state that there are always enough staff working in the home to meet their needs. EVIDENCE: The manger stated to the inspector that she uses the residential forum to calculate the number of hours required by the staff to work in the home every week. Interviews with the staff showed that they had a clear understanding of their own and their colleague’s responsibilities. They also confirmed that they had received copies of the General Social Care Councils codes of conduct had practice. There were no volunteers working at the home. The home employs sixteen care staff. Two of the staff have completed the NVQ 2 award in care and a further seven staff are registered on the award and working towards completing it. The manager and care staff were positive in their attitude towards NVQ training. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 20 The home has quite a static staff group. There had been very little change to the staff working at the home since the last inspection. Service users spoken to by the inspector stated that the staff ‘listened ‘ to them and were ‘very helpful and supportive’ towards them. The service users said that they were very happy with all of the staff including the care and domestic staff working in the home. One of the senior staff at the home has been delegated as the training coordinator to ensure that all of the staff receive their updates for their mandatory training and identify any specialist training that may support the staff in the care of the service users. The inspector observed staff personnel records and these supported the evidence that the home operates a thorough recruitment procedure that is based on equal opportunities and ensures the protection of the service users. New staff do not commence work until after they have receive clearance through a POVA first and then only work under supervision until their full CRN is returned to the home. The staff files also included records of their interviews, two written references and personal identification documents. Induction training is provided through an external trainer and it identifies that it meets the appropriate training targets to fulfil the aims of the home and to meet the changing needs of the service users. The management of the home must ensure that formal recorded supervision of the staff is urgently established in the home to monitor their training needs and to ensure that they are meeting the needs of the service users through their individual care plans. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 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): 37,39,40,41,42 and 43 The management of the home ensures the protection and welfare of the service users. EVIDENCE: The manger of the home is a registered nurse and SEN. She is also an NVQ work base assessor. The manager of the home has recently completed a postgraduate degree in psychology. The manager of the home has not completed the Registered Managers Award and does not show much commitment to completing it. She explains that, as well as managing the home, she is also responsible for all of the home’s administration and manually dealing with staff wages. This does not leave her with time at work to complete the award. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 22 The manager joins the staff in the mandatory training that is undertaken at the home. The home does not have an effective quality assurance and monitoring system in position. The manager sent out quality questionnaires in October 2005 to the service users, however, at the time of the inspection these had not been appraised and an action plan had not been developed from the findings. The results had, therefore, not been published. The home requires this system to be available and to be robust to ensure that it is capable of meeting the needs of the service users. The manager of the home reviews the home’s policies and procedures on an annual basis. All of the policies required by regulation were appropriate and were available to the staff and service users. All of the records that are required by regulation for the protection of the service users and for the effective running of the business were in place. Daily diary records in relation to the service users were much improved and included clearer details of what they are involved in on a daily basis. The quality of the information included in individual care plans had also improved. The health and safety records for the home were all up to date. This included appropriate insurance cover for the business and safety certificates for the electrical and gas systems at the home. The home is waiting for its legionnaires testing certificate to be delivered. The management should consider how used sanitary pads are disposed of. The fire doors in the smoking lounge and the lounge off the dining area are in need of repair or replacement as they are beginning to rot. The extractor fan in the smoking lounge needs to be replaced. It is very noisy and, therefore, the service users turn it off. This means that there is a constant build up of smoke in the rooms that then spreads into other areas of the home. The home has a current business plan that takes it in to 2007. This needs to be developed further to show the home’s prospective income and outgoings for that period to support the company’s financial security and the business viability. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 23 The stairway down to the cellar is steep. This should be provided with a handrail on both sides to ensure the safety of the staff using this access. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 3 32 1 33 3 34 3 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 X 1 3 3 2 3 Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 25 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 YA32 Regulation 19 Requirement The registered person must ensure that a minimum of 50 of the care staff have achieved NVQ 2 or equivalent. The registered person must ensure that all care staff receive formal recorded supervision a minimum of six times per year. The registered person must ensure that the manager of the home has achieved the registered managers award or equivalent. The registered person must ensure that the home has an effective quality assurance and monitoring system that supports the needs of the service users living at the home. Timescale for action 31/07/06 2 YA36 19 01/05/06 3 YA37 9 30/06/06 4 YA39 24 01/06/06 Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 26 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 7 8 9 10 Refer to Standard YA1 YA2 YA8 YA17 YA17 YA28 YA42 YA42 YA42 YA42 Good Practice Recommendations The homes statement of purpose and service user guides should be updated to include the details of the new proprietors to the business. The registered person should make sure that the homes pre-admission assessments of service users needs are more detailed. The registered person should ensure that service user meetings are held more regularly at the home and that the meetings are recorded. The registered person should supply more appropriate table clothes and pace settings for the dining room. The registered person should consider changing the dining chairs for a more comfortable substitute. The registered person should consider changing the lighting that is provided in the dining area. The registered person should provide appropriate safe disposal of sanitary wear. The registered person should replace the extractor fan in the smoking lounge. The registered person should repair or replace the fire doors identified in the report. The registered person should fit a handrail to both sides of the stairs leading down to the cellar to ensure the safety of the staff that have to access this area. Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Sussex House DS0000064150.V281690.R01.S.doc Version 5.1 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!