Inspection on 22/10/07 for The Old Rectory

This inspection was carried out on 22nd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Rectory 23/05/07

The Old Rectory 11/12/06

The Old Rectory 10/11/05

The Old Rectory 16/12/04

The Old Rectory 21/07/04

The Old Rectory 23/01/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 The Old Rectory 45 Sandwich Road Ash Canterbury Kent CT3 2AF Lead Inspector Gary Bartlett Key Unannounced Inspection 22nd October 2007 9:30 The Old Rectory DS0000023705.V350400.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 The Old Rectory DS0000023705.V350400.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. The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Rectory Address 45 Sandwich Road Ash Canterbury Kent CT3 2AF 01304 813128 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 Rex Slade Cadman Mr Rex Slade Cadman Care Home 40 Category(ies) of Learning disability (40) registration, with number of places The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users over the age of 65 years old are restricted to four (4) whose DOB`s are 04/03/1940; 26/04/1939; 24/03/1937; 27/02/1940. 23rd May 2007 Date of last inspection Brief Description of the Service: The Old Rectory is a 40 bedded home. The home has been established for over 25 years and provides personal care and support to people who have learning difficulties. The home is on the outskirts of the village of Ash, which has reasonable local facilities. The home has its own transport and there is a major bus route nearby linking the village with Canterbury to the west and Sandwich, Ramsgate and Deal to the east. The building comprises a large house, which has been extended over the years. Accommodation is set over three floors with a range of both communal and individual space. The provider/manager also runs another home nearby for 5 service users. The fee for living at this home ranges from about £323 to £550 per week approximately. For more information about the fee and what it includes please contact the Provider. The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in The Old Rectory from 9:30 a.m. until 6:20 pm. Due to the nature of the service, it is difficult to reliably incorporate accurate reflections of the residents in the report. Some judgements about quality of life and choices are taken from direct conversation and physical responses with people living in the home as well as direct observation followed by discussion with staff and a visitor, evidencing records and care plans held at the home. A tour of the house was undertaken. A large number of survey forms were received prior to the inspection. Residents and their relatives responded that they like the home and think there are good standards of care. Survey forms completed by service users included the comments: • “I am very happy”. • “I like living here”. Other statements made are quoted in the text of the report. The Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older People refer to people who use the service as “service users”. People living at The Old Rectory prefer to be referred to as “residents”. Accordingly this shall be done in the text of this report. The Manager and staff gave their full co-operation throughout the inspection. The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home has made further improvements since the last inspection. Residents’ care plans are being updated and risk assessments are being improved. Care practices and records are being monitored more closely. Staff training is being more effectively managed. More robust recruitment processes are being used. Staff are receiving regular supervision and appraisals. The environment and facilities are being enhanced. Standards of hygiene and infection control are being improved with better cleanliness around the home and the refurbishment of the toilets and bathrooms. There are now improved arrangements for the giving of medicines. medicines refrigerator has been obtained. A Systems to safeguard residents’ monies have been reviewed and improved. Policies and procedures are being reviewed and updated to comply with current legislation and good practice guidelines. The home’s fire risk assessment has been reviewed to comply with recent changes to legislation. The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. The Old Rectory DS0000023705.V350400.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 The Old Rectory DS0000023705.V350400.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements are being made to the assessment of residents’ needs. EVIDENCE: Most residents have been living at The Old Rectory for several years. There are not pre-admission assessments for these people. It is recognised that the improvements made to residents’ care plans must be extended to include residents’ aspirations and more detailed assessments of communication. There was discussion about the value of using independent advocates where residents do not have regular family or Care Manager contact. The Old Rectory DS0000023705.V350400.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 and 10 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ care plans, risk assessments and guidelines are being developed to ensure consistent support by staff in meeting residents’ individual health and social care needs. EVIDENCE: All residents have a care plan. Since the last inspection, further work has been done to develop them to ensure the information is up to date. This should be extended to include important information about a person’s life, their past and their aspirations. The standard of daily record keeping is generally better. The Manager is aware that some records need to be more consistently detailed to accurately reflect care given and is addressing this through the regular review of records and by staff training. The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 11 Risk assessments are being improved and written/reviewed in response to incidents and accidents, although this still needs to be more consistent. Policies and procedures are being updated and guidance sought to promote residents’ health and welfare. Records seen and discussion with residents indicate they are supported in making regular dentist, optician and other health appointments. Training is being provided so staff can meet the health care needs of the residents. The Manager values the regular contact with residents’ families and their representation of residents’ behalf. Placing authorities’ Care Managers can also make representation on behalf of residents. The home still does not make other advocacy available to enable residents to have an independent communication of their needs, views and choice. Interaction between the residents and staff is good showing genuine respect, friendship and appropriate familiarity with each other. Some records of personal information are being recorded collectively, thereby compromising confidentiality. The Manager undertook to address this. The Old Rectory DS0000023705.V350400.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents have opportunity to take part in a variety of activities and are supported to access the community. Residents personal skills and independence should be better promoted. Residents enjoy the food. EVIDENCE: Residents said they generally have enough to do and spoke about a variety of activities they take part in. They said they enjoy going into the village to the local shops and to visit friends nearby. As personal goals and aspirations are not consistently recorded it is difficult for the home to routinely support residents’ individual preferences. However, staff spoken with have a good understanding of residents’ tastes. One resident regularly catches the bus to The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 13 Canterbury and other places in the vicinity. A meal is saved for him to have when he returns. The Old Rectory is a large home and this necessitates effective communication systems to ensure all residents know what is being offered. This should be done in such a way as to promote residents’ independence and take account of their abilities. For example, residents currently can only find out what is for lunch by asking staff. There was some discussion about the merits of using a board with this information utilizing pictorial representation for those with limited literacy skills. There was also discussion about how the minutes of residents’ monthly meetings could record that the forthcoming menu was discussed with residents. From current records it is not clear that alternative meals are available or that residents nutritional needs are assessed or regularly reviewed. Staff say that residents’ individual tastes are catered for. Survey forms completed by residents included the comments: • “ Nice food”. • “I like the food”. A visitor said staff are very welcoming and good at keeping them informed. The Manager said the current refurbishment programme includes the fitting of locks to toilets, bathrooms and bedroom doors. The bedroom door locks fitted so far can only be locked from the outside. The Manager said this is a fire precaution. There was some discussion about the desirability that locks fitted to residents’ bedroom doors be a type that can be locked from inside and outside and comply with current fire safety requirements. Residents’ wardrobes are being fitted with locks to provide secure storage space. The Old Rectory DS0000023705.V350400.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvement in the recording of personal care needs gives a better indication how residents’ health needs are being met. Residents are protected by the appropriate administration of medicines. EVIDENCE: Personal care needs are being better recorded in individual care plans. It is anticipated that the plans will be further developed to include more emphasis on maximising and maintaining independence. Residents say they have the support they need with personal care and think that the bathrooms and toilets are adequate. The improvement to some bathrooms is particularly appreciated. The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 15 Residents confirm they have support to make appointments and see the doctor and other health care professionals when they need to. Records show that all staff administering medications have been trained and signed off as being competent to do so. The Medication Record Administration Record (MAR) sheets inspected had been completed appropriately. The administration of medicines was not observed on this occasion. The cupboard used for the storage of medicines is well maintained but the temperature is not being monitored. This must be done to ensure medicines are stored at the recommended temperatures. However, the temperature of the recently acquired medicines refrigerator is being checked. The Clinical Consultant said that a controlled drugs book has been requested from the pharmacist. The Old Rectory DS0000023705.V350400.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents would be better able to express concerns if the complaints procedure was available to them in a format they can more understand. Protection from abuse is being promoted through staff training. EVIDENCE: The home has a complaints procedure. It is evident a large number of residents are reliant on a relative or staff to identify concerns and raise them on their behalf. Accordingly, to promote independence, the complaints procedure must be available to the residents in a format they can easily understand. The Manager said there had not been any complaints received since the last inspection. He stated that a system had been introduced whereby all complaints, formal and informal, would be recorded with details of the investigation, outcome and of any resultant action. A resident’s relative said she is confident that if she had any concerns or complaints they would be treated seriously. The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 17 Staff have recently undertaken POVA training and the Safeguarding Adults procedures updated. The Manager and staff spoken with have a good understanding of procedures to safeguard adults. An adult protection investigation in respect of the care at this home has been closed recently. The home’s policies and practices regarding residents’ monies and financial affairs have been significantly changed. The Old Rectory DS0000023705.V350400.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements are being made to the home to provide a comfortable environment for residents. EVIDENCE: As mentioned earlier in this report, there is a programme of improvement for the building. This includes improvement to bathrooms, toilets and a move to more single occupancy bedrooms. During the building works it is difficult to keep all parts of the home clean but staff and residents are making their best efforts. It is also important that residents are kept safe. Staff and building contractors are reminded of the need to be particularly vigilant whilst building works are in progress. The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 19 The communal areas are spacious and varied so residents can choose where to spend time. The Manager is keen to allow residents to use the external fire exits for easier access to parts of the house and the garden. There was some discussion about the need to continually review recorded risk assessments in respect of this. All laundry is done on site. The washing machine has a sluicing programme. Infection control would be better maintained if soiled clothing and linen was transported to the laundry in sealed bags designed to be placed directly into the washing machine. Appropriate hand-drying facilities must be provided in communal washing areas and the laundry to promote infection control. The Old Rectory DS0000023705.V350400.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Robust recruitment processes are followed to ensure only staff properly vetted work at the home. There are improved staff training and supervision arrangements so staff to have the core-skills they need. EVIDENCE: Survey forms completed by service users included the comments: • “I like the staff”. • “Staff always nice”. Survey forms completed by health professionals included the comments: • “Caring and friendly service”. • “The staff I have met are all pleasant, caring people”. Survey forms completed by relatives included the comments: • “They do a very good job”. The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 21 • “We have every confidence in the staff”. Since the last inspection, a comprehensive core-skill training programme has been put in place and is managed with the use of a training matrix. Staff supervision is now regularly undertaken, as are staff appraisals. Records seen indicate that robust recruitment procedures are used and all new staff are required to undertake an induction programme. As the service progresses towards providing more individualised personcentred support, staffing levels and training will need to be developed further. The Old Rectory DS0000023705.V350400.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. More effective management systems are being implemented to safeguard residents’ interests. The quality assurance system should be developed to show that improvement and development is based on service users views. EVIDENCE: A survey form completed by a care manager included the comment: • “The relaxed atmosphere and family feel make this an exemplary home”. The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 23 In response to the last inspection report, more effective management systems are being implemented to safeguard residents’ interests. A Clinical Consultant is being employed to give professional advice and assistance. It was established at the last inspection that the Manager said he had completed an NVQ level 4 in care qualification that was being verified and certificated. Systems to safeguard residents’ monies have been reviewed and improved. A lot of work has been done to review, write and update policies and procedures so they comply with current legislation and good practice guidelines. Care practices and records are being monitored more closely. The Manager stated a fire risk assessment has been written. Confirmation should be sought from the Fire Safety Officer that it complies with current regulations. The kitchen must be kept cleaner and food stored in accordance with its directions to meet with food hygiene requirements. The Old Rectory has some quality assurance and monitoring tools in place. Residents are given questionnaires on a regular basis for their views on the home and the service they receive. Currently there is no evidence to show if their views are acted on and what the out-comes are. The Old Rectory DS0000023705.V350400.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 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 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 2 X 2 2 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 1 2 2 2 X The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 25 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 14(2)(b), 15(2), 17 Schedule 3, Schedule 4 Requirement The registered person shall maintain records as specified in Schedules 3 and 4. The registered person shall keep the service user’s plan under review in that service users’ individual plans and records must be kept and be up to date in that they must be consistent and specific in detail of information required. Whilst it is acknowledged there has been much work done towards this, all service users must have an accurate care plan by the given timescale, if not sooner, which is thereafter maintained. Timescale for action 01/03/08 2. YA7 12(3) “The registered person shall , for 28/02/08 the purpose of providing care to service users, and making proper provision for their health and welfare, so far as is practicable ascertain and take into account their wishes and feelings” in that staff must help service users, if they wish, to have independent advocacy. To be completed by the given The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 26 3. YA9 13(4) 4. YA10 12(4)(a) timescale, if not sooner and maintained thereafter. The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated in that risk assessments must be more comprehensive and recorded in response to incidents and changes in residents welfare. Whilst it is acknowledged there has been much work done towards this, all necessary risk assessments must be in place by the given timescale, if not sooner, and maintained thereafter. “The registered person shall make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users”, in that records must be made in a manner that preserves confidentiality, ie service users or concerned parties must be able to read records made about them without viewing personal information pertaining to other people. To be completed by the given timescale, if not sooner and maintained thereafter. “The registered person shall make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users”, in that: 1. All bedroom doors must be fitted with appropriate locks. 2. Lockable facilities be provided in residents bedrooms to securely DS0000023705.V350400.R01.S.doc 01/03/08 30/11/07 5. YA16 12(4)(a) 01/03/08 The Old Rectory Version 5.2 Page 27 store valuable itrems. It is acknowledged that work to achieve this has commenced. To be completed by the given timescale, if not sooner and maintained thereafter. “The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users” in that service users’ nutritional needs must be assessed and reviewed regularly. To be completed by the given timescale, if not sooner and maintained thereafter. The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users and make arrangements for the recording, handling, safekeeping, safe administration of medicines in that the temperature of the medicines storage area must be regularly monitored. To be completed by the given timescale, if not sooner. “The complaints procedure shall be appropriate to the needs of the service users” in that the complaints procedure must be made available to the service users in a format they can easily understand. To be completed by the given timescale, if not sooner. The registered person shall ensure that all parts of the home to which service users have DS0000023705.V350400.R01.S.doc 6. YA17 12(1)(a) 31/01/08 7. YA20 13(2) 15/11/07 8. YA22 22(2) 31/01/08 9. YA24 13(4) 31/12/07 The Old Rectory Version 5.2 Page 28 access are so far as reasonably practicable free from hazards to their safety in that a recorded risk assessment of service users’ access to all parts of the home, with particular regard to the external fire exits and roof areas, must be undertaken. To be completed by the given timescale, if not sooner and maintained thereafter. 10. YA30 12(1), 13(3)(4) (c) 16(2)(j) The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home, in that: 1. Appropriate hand-drying facilities must be provided in all communal washing areas, toilets and the kitchen. 2. Appropriate arrangements must be made for transferring soiled items to the laundry. To be completed by the given timescale, if not sooner and maintained thereafter. 31/12/07 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 YA16 Good Practice Recommendations It is recommended that the care plans be made available to residents in a format they can more readily understand. It is strongly recommended that locks fitted to residents’ bedroom doors are of a type that can be locked from DS0000023705.V350400.R01.S.doc Version 5.2 Page 29 The Old Rectory 3. 4. YA20 YA39 5. YA42 inside and outside and comply with current fire safety requirements. Residents should be provided with keys unless their risk assessment suggests otherwise. It is strongly recommended a printed controlled drugs register is obtained. It is strongly recommended the home introduce a more effective quality assurance and quality monitoring system, based on the views of service users and other stakeholders. It is strongly recommended that confirmation be sought from the Fire Safety Officer in respect of the suitability of the fire risk assessment. The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 The Old Rectory DS0000023705.V350400.R01.S.doc Version 5.2 Page 31 - 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!