CARE HOME ADULTS 18-65
Sycamores 33 Dymoke Road Hornchurch Essex RM11 1AA Lead Inspector
Ms Rhona Crosse Key Unannounced Inspection 28th July 2006 09:15 DS0000027873.V305033.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000027873.V305033.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000027873.V305033.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Sycamores Address 33 Dymoke Road Hornchurch Essex RM11 1AA 01708 726933 01708 707370 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) Mr Michael Joseph Prior Mrs Harjinder Kaur Prior Mrs Harjinder Kaur Prior Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000027873.V305033.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 27th June 2006 Brief Description of the Service: Sycamores is in a residential area of Hornchurch and is within walking distance of Romford market town. The home offers 24 hour care for 5 adults with learning disabilities. The home accommodates males only. All accommodation is in single bedrooms one bedroom has an en-suite facility. 2 bedrooms are on the ground floor and 3 are on the first floor. The home is not suitable for anyone who uses a wheelchair as the corridors are narrow and there is no passenger lift to the first floor. DS0000027873.V305033.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The home continues to provide a good standard of care for service users with staff being knowledgeable about the needs and changes of service users care. There is a genuine commitment from staff to provide service users with a good quality of life and support them to make appropriate choices. Service users are happy living at the home and appear to get on well with each other. Relatives are encouraged to visit at any time and arrangements are also made by the home to take service users to visit relatives and collect them at an agreed time. This is seen as good practice. Staff training is taking place although there are some outstanding requirements made at the last inspection relating to staff training that have not been achieved. These requirements have been restated in this inspection. Activities are taking place and service users spoke about these to the inspector. What the service does well:
The home is very welcoming and the service users consider it to be ‘their home’ and take a pride in living at the home. Their comments and choices are acted upon and they spoke freely about the home and the staff as well as the activities they have recently participated in to the inspector. Health care needs are being met with referrals to health professionals and the community learning disability team as necessary. Medication practice was good with all medication administration records corresponding with medication held. All but one care plan was current, with service users signing or making their ‘mark’ to evidence that this plan of care had been discussed with them in terms as far as their abilities allow. A new staff member was interviewed and showed a good understanding of the needs of the service users. The staff member had had an induction to ensure that she was aware of the operation of the home. Money held in safekeeping for service users and the documentation was inspected. Money held corresponded with the receipts kept and the records held. In discussion with relatives the quality of care was said to be good. Comments made were: ‘We are very happy with the care’. ‘The general feeling of the place is homely and the service users interact well with each other and the staff’. ‘It feels like a family home, a home from home it’s a great place.’ ‘Our relative is happy if he wasn’t he would tell the family, he is always happy there and gets on well with everyone’. ‘Jinder is doing a fine job, she is very caring’. ‘The outside day services for my brother have changed; this has resulted in him being depressed and not having enough to do in his life, he felt he was contributing before now he just
DS0000027873.V305033.R01.S.doc Version 5.2 Page 6 has 2 days at a centre so from that point of view his life is not as good as it used to be’. ‘We have no qualms about the service that is provided. Communication could be better at times. I recently visited to find that they had gone away for the weekend, it would have been nice if we had been told as it was a wasted journey to the home’. All the staff seem very nice’. Other comments were: ’We are very happy Jinder and the staff do an excellent job, if we have raised any health concerns they have been immediately addressed’. ‘Jinder has encouraged our son to socialise more and has encouraged him to go out. When they manage to encourage him to go out (he recently had a pub lunch) Jinder lets him ring us on the mobile phone and he tells us where he is and that he has had to eat, it is those kind touches that make all the difference’. Further comments were: ‘The service is very good we have no complaints Service users are happy there and our relative gets on well with everyone. The day services provided in Havering are not as good as they used to be’. What has improved since the last inspection? What they could do better:
One care plan had not been updated when a change had been made. All care plans must be updated as soon as a change is noted and hold the appropriate information. However due to the size of the home (5 service users) the staff were aware of the changes and demonstrated this in discussion with the inspector. Therefore in this case the lack of updating the care plan had not had a detrimental effect on the care of the service user. Although goals have been set for service users these need to be expanded and worked upon to cover a wider range of skills particularly for one service user DS0000027873.V305033.R01.S.doc Version 5.2 Page 7 who has lost the day services that he had had for many years and this has resulted in him becoming depressed. There were requirements set at the last inspection in relation to staff training that has not been achieved. All staff must undertake lifting and handling, basic first aid, food hygiene, dealing with challenging behaviour, health and safety and Epilepsy. The majority of the home was well maintained. The upstairs W.C. requires decoration and the seal around the floor covering in the room has come away and must be resealed. The manager has already identified a repair required to one service users vanity unit. The maintenance man was to repair this on his return to duty. 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. DS0000027873.V305033.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000027873.V305033.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 & 5 The quality in this outcome area is good therefore there are more strengths that weaknesses. There have been no vacancies since the last inspection therefore this standard remains met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are no vacancies at the home. The service users have been at the home for some time. Prior to admission any prospective service user is assessed by the home to ensure that the home can meet their needs. Service users are encouraged to visit the home prior to admission. This can be a short visit to have a meal at the home or a longer overnight or weekend stay. The length of the admission process would be in line with the individuals needs and wishes. DS0000027873.V305033.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 The quality in this outcome area is good therefore there are more strengths that weaknesses. In general information held was of a good standard with staff being aware of particular needs and wishes, evidencing that the needs and wishes of service users are met as far as possible enhancing their daily lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are written up for all service users. However for one service user there had been a change in the needs of the person. The care plan did not document this change although the staff are aware of the changes. As this home has only 5 service users and communication is good, the lack of updating of the care plan has not had a detrimental effect on the service user’s care. All changes must be recorded and the care plan update with current information. Goals have started to be set for service users. The manager stated that it is really difficult to set goals as the service users loose interest in things and will not always participate. Goals should be set in line with service users needs and
DS0000027873.V305033.R01.S.doc Version 5.2 Page 11 the home must look at ways of expanding these goals as they are very basic at present to enable service users to reach their potential. For one service user going out has been a difficult task due to anxiety. However the home have worked hard to include the service user in activities outside the home and the service user is now venturing out more often with a lot of support. This was a goal set for this particular person and this is working well. For 2 other service users who like animals a goal to feed and groom the pets has been set. When the manager/proprietors dog visits they take turns in caring for the dog whilst it is at the home. From observation of care practice it was observed that service users make decisions about what they want to do and they are enabled to do this. All will help with the daily activities within the home depending on their abilities. Some are more reluctant to assist but none are put under any pressure to participate if they choose not to help. Where there is an identified risk, risk assessments are drawn up. DS0000027873.V305033.R01.S.doc Version 5.2 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 & 17 The quality in this outcome area is good therefore there are more strengths that weaknesses. The home takes service users choice and rights into consideration enabling them to have a say in the daily life of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since moving to the home the service users accommodated have an improved quality of life. Service users use the services in the local community for GP and other health needs, shopping and hair dressing. Two service users go to local day projects, one service user attends ½ a day per week. Activities take place and these are based around the wishes of the service users. One service user likes to travel on trains but there was no record of this taking place for some considerable time. The home should ensure that this opportunity is offered again. When checking the opportunity plans and activities recorded it was observed that several activities that were recorded in
DS0000027873.V305033.R01.S.doc Version 5.2 Page 13 the daily records were not recorded on the service users opportunity plans. All activities should be recorded on the opportunity plans of service users. A trip to Hastings took place on the 21/5/06. A trip to Clacton took place on the 1/7/06 and another trip to Aylesford took place on the 9/7/06. These trips are arranged through the clubs that the service users attend. The annual holiday has not been discussed as yet, but this is usually a holiday abroad. Trips out to local restaurants and cafes take place. One service user told the inspector ‘we went out to lunch yesterday in Romford, I enjoyed that’. It was recorded that service users went out for a ‘pub’ lunch on the 5/7/06. For one service users going out has been a difficult task due to anxiety, however the home have worked hard to include the service user in activities outside the home and the service user is now venturing out more often with a lot of support. Links with families and friends are encouraged and there are no restrictions placed on visiting times. No relatives were visiting at the time of the inspection. In a telephone conversation with relatives they all felt that the service the home is providing is good. Service users have the same rights as anyone living in the community. Along with being able to exercise their rights service users have to be aware of the risks and their responsibilities. This is explained to them in terms that they understand. Any risks relating to independence and activities are recorded as part of the care planning process. Meals and meal times are generally arranged around the daily activities that are taking place. The main evening meal is when all service users and staff sit down together. Menus are generally kept to unless service users make requests for something different. This is then recorded on the menu. From inspection of the menu, changes were observed to be recorded. Fresh fruit was observed to be available at the time of the inspection. The menu made reference to choices of deserts and stated see ‘over leaf’. However there were no choices recorded and no record of what service users had eaten as a desert. This must be addressed with a record always kept of all meals service users eat. DS0000027873.V305033.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 The quality in this outcome area is good therefore there are more strengths that weaknesses. Referrals are made to health professionals as necessary ensuring the ongoing health and welfare of service users is appropriately dealt with. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users are self caring requiring only supervision and encouragement with personal hygiene. There is a male carer and one of the proprietors is a male, should a service users wish to be assisted by a male or discuss anything of a personal nature that they may not wish to discuss with female staff. Health care needs are well monitored and referrals to health professionals were recorded when visits or hospital appointments were made. In discussion with one member of staff the current needs of a service user were discussed. The staff member was informative about the changes in the needs of the service users and showed empathy in her discussion about issues that may become a problem if not dealt with appropriately. Medication practice was inspected. None of the current service users is able to take responsibility for the administration of their own medication. All medication held corresponded with the medication administration sheets.
DS0000027873.V305033.R01.S.doc Version 5.2 Page 15 Medication reviews take place and one service users mediation has recently been reviewed and changed as a result of this. DS0000027873.V305033.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The quality in this outcome area is good therefore there are more strengths that weaknesses. The home has an open culture where comments made by service user are listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an ‘open’ culture where service users have demonstrated at inspection that they feel able to tell staff and management if they are worried or unhappy about anything. One service user stated ‘I would tell Jinder if I was worried about something and she would sort it out’. The home has policies and procedures for making a complaint. The manager is currently reviewing all policies and procedures as the ones she purchased from a Consultancy group are not thorough enough. There have been no complaints made to the home, no complaints have been received by the Commission. Not all staff have received training in the protection of vulnerable adults. This training must be provided and is a restated requirement from the last inspection. However in discussion with a new member of staff she was able to discuss the process she must take if she witnessed poor care or any form of abuse. Part of the induction programme covers the protection of vulnerable adults. The home also has copies of Havering Adult Protection procedures. Service users money held in safekeeping was inspected. The records corresponded with purchases made and money held was correct. Money
DS0000027873.V305033.R01.S.doc Version 5.2 Page 17 deducted from building society books to keep funds for service users at a reasonable level were to be entered onto the records by the manager. DS0000027873.V305033.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30 The quality in this outcome area is good therefore there are more strengths that weaknesses. The needs of the service users in relation to the environment are taken into consideration when any decorating is undertaken. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The house is very homely and is maintained to a good standard. Since the last inspection the lounge has had new furniture and a new carpet. The hallway, landing and stairs have been decorated and has also had new carpeting fitted. Service users bedrooms are all very individual and full of their own possessions. Décor is their choice and one service user is changing his bedroom wall colour. Service users can lock their bedrooms if they choose to do so. The main bathroom was clean and free from odours. The upstairs W.C. requires decorating and the flooring sealed as the seals have come away around the floor covering next to the toilet.
DS0000027873.V305033.R01.S.doc Version 5.2 Page 19 The kitchen and dining room were in good order. Garden furniture was in the garden and the service users make good use of the garden. The laundry room was clean and tidy. The home is not suitable for anyone with physical disabilities therefore there are no aids and adaptations provided. DS0000027873.V305033.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 The quality in this outcome area is good therefore there are more strengths that weaknesses. The home ensures the ongoing safety of service users by having good recruitment and selection processes. Further training identified for staff to achieve will enhance this further. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a recruitment and employment procedure. One staff member has been recently employed and is still within the probationary period. The employment file held all the appropriate information. The staff member had undertaken an induction programme to ensure she was aware of the needs of the service users and the running of the home. The manager has completed her NVQ level 4 in management and is awaiting the results. 6 members of staff are undertaking the NVQ level 2 qualification and a further 3 still need to be put forward for this training. The home is aware that 50 of the staff must be trained to NVQ level 2. The manager is currently looking at the training all staff have taken and is completing a training record for all staff. Once completed it will identify which staff require particular courses or refresher courses. All staff must hold basic food hygiene, basic first aid, moving and handling, infection control, fire
DS0000027873.V305033.R01.S.doc Version 5.2 Page 21 training and health & safety. Due to the current client group staff should also receive training in challenging behaviour and Epilepsy. Some staff have received training this year in food hygiene and health and safety. Since January nine staff have received formal written supervision. The manager is working through the staff group to ensure that all staff have the minimum of 6 formal written supervision sessions per ‘rolling’ year. DS0000027873.V305033.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The quality in this outcome area is good therefore there are more strengths that weaknesses. The majority of health and safety information was held however the manager must ensure that all health and safety documentation is monitored and renewed as appropriate for the protection of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has not yet commenced a quality assurance questionnaire. This was being looked into as part of the managers NVQ level 4 qualification. A questionnaire has been drawn up and is to be sent to service users relatives and visiting professionals. Comments from service users must also be added to the analysis. Once this information is returned an analysis of the findings should be made and the result should form part of the new Service Users Guide.
DS0000027873.V305033.R01.S.doc Version 5.2 Page 23 Service users meetings are not taking place. These should be reinstated to evidence that the home is taking into consideration the wishes and requests of service users. Although none of the present service users have requested advocacy service these could be made available should the need arise. The health and safety certificates and documents relating to the servicing of equipment in the home was inspected. The 5 year electrical certificate is dated 6/8/05 and the portable electrical appliances were tested on the 19/6/06. The Legionella test of the water system is due to be undertaken again in August 2006. The annual Gas safety certificate is dated 20/4/06. The homes insurance certificate is current the renewal date is 2/12/06. The last fire drill took place on the 13/12/06 the home is aware that there must be 4 drills within one year. The most recent member of staff has not been present when a fire drill has taken place. The home must ensure that she is included in the next fire drill that is undertaken. In discussion with that staff member she was aware of what to do in the event of a fire and could identify the collection point. The fire extinguishers are due for their annual service in August. The last fire alarm service was recorded as being in September 2005, the manager must ensure that the alarm system is serviced every 4 months. The weekly fire alarm test was over due by 3 days (the last check was recorded as taking place on the 18/7/06). The home must ensure that the weekly test is carried out to ensure the system is working appropriately. The homes policies and procedures are currently under review and changes will be made as necessary. Staff have access to policies and procedures to refer to at any time. The staff member spoken with was are aware of the lines of accountability within the home and was clear about her role and responsibilities. DS0000027873.V305033.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 2 28 3 29 N/a 30 3 STAFFING Standard No Score 31 x 32 X 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 x LIFESTYLES Standard No Score 11 x 12 2 13 3 14 x 15 3 16 x 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 2 X X 2 X DS0000027873.V305033.R01.S.doc Version 5.2 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 YA6 Regulation 15(1) & (2) Requirement Care plans must be updated to reflect the changing needs of service users. All activities undertaken should be recorded on the opportunity plan for each service user. Menus must reflect the deserts that are offered and a record kept of the choice service users make for deserts. All staff must have training in the protection of vulnerable adults. This is a restated requirement from the last inspection. Decorate the upstairs W.C. Reseal the floor covering behind the W.C. All staff must have training in basic food hygiene, basic first and lifting and handling. This is a restated requirement from the Timescale for action 30/08/06 2 YA12 15(1)9a) & 16(2)(n) 30/09/06 3 YA17 17(2) schedule 4 13 30/08/06 4 YA23 13(6) 30/10/06 5 6 7 YA27 YA27 YA35 23(2)(d) 23(2)(b) 18(1)(c)(i) & (13(5) 30/09/06 30/09/06 30/11/06 DS0000027873.V305033.R01.S.doc Version 5.2 Page 26 last inspection. 8 YA35 18(1)(c)(i) All staff must have training in dealing with challenging behaviour. This is a restated requirement from the last inspection. 30/10/06 9 YA35 18(1)(c)(i) 10 YA39 24(1)(a) & (b) 11 YA42 23(4)(e) All staff must have 30/10/06 training in Epilepsy (due to recent admission). This is a restated requirement from the last inspection. A quality assurance 30/11/06 system must be put in place. With an analysis of the outcome of the questionnaire forming part of the Service Users Guide. Ensure the new staff 30/09/09 member is included in the next fire drill to be undertaken. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA42 Good Practice Recommendations It is recommended that the manager monitors that all health and safety documentation is being dealt with appropriately. DS0000027873.V305033.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 DS0000027873.V305033.R01.S.doc Version 5.2 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!
